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I?- What is the depth to groundwater? <br /> Describe the source of Information: /// <br /> 13. Are there any water wells on this parcel or adjacent properties? YES,{Q NO` <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> irrigation Well rL <br /> 1=, <br /> Monitoring Well S ft 2I-'t c <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?YES[]Nll(� <br /> 15. Indicate the responsible party to be billed for additional PHSEHD staff time expended beyond 3 hour minimum <br /> permit payment <br /> per tank. If the party designated below Is different than the permit applicant,a g.property owner,the party must acknowledge <br /> this responsibility for the billing by signature and date be/low. <br /> C_ <br /> Name "5/9/t/N��y? / N� �/g��N C— 1 <br /> Mailing Address � TlS J c � F7G769 <br /> �7��«� � 57665 '/On/ 091Day Phone Number���0//��—/ ) 9 /3 .3 © <br /> /0 — O <br /> Signature /� Title Date <br /> "D ZU'l GyY/U P <br /> EH 23 046 (Revised 10/19/98) Page 6 <br />