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12. What is the depth to groundwater? _„akaoW J CA94iox �� I$-�� J <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YESNO <br /> TYPE OF WELDS 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[ ] NON <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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name U"L- 11 !� <br /> Mailing Address ��yJ ?Qo 11 l-:)' l � Sv,�Q (4010 \ /0O OIC-c'y" 1 � C5k <br /> A k\(S—) <br /> Day Phone Number ( --)ol <br /> tA=p�_ Mon 2 ] 9 g <br /> Signature Title3 Date <br /> • <br /> EH 23 046 (Revised 9/11/96) Page 6 <br />