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12. What is the depth to groundwater? �� wuallC+�h <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [ ] NO [ ] <br /> TYPE OF WENS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO[�— <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum <br /> permit payment per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name _5' HNr F—t�Y,A0 y�I ^ <br /> Mailing Address 34 �D TD� ��i� p�� K l r ��� / lett 9 DM <br /> Day Phone Number ( 3 C) ) 1 a2- �-72-g <br /> S" I -Yj� 8 / 10 <br /> Signature Date <br /> Page 6 <br />