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i <br /> 12. What is the depth to groundwater? 7 <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES NO[] <br /> TYPE OF WELLS I 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 <br /> tank(s)?YES[]NOW <br /> 15. Indicate the responsible party to be billed for additional 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 P&9=&b I c D iAUAkRi u+k. 1)4L. <br /> Mailing Address I�POU wjLUP, +s tT Clau ���DRt� a TfSl`j <br /> Day Phone Number('.51 O 90 fs)'-I rJ3 <br /> "iy foe-D"'414�L, A2 <br /> Signature Title Date <br /> EH 23 046(Revised l0/16/03) Page 6 <br />