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What is the depth to groundwater? 6S T�m9T�b CSO <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? YES [ I NO [ J <br />TYPE OF WELLS I <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES NO( J <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 JMA9&;-1+0-) 81'IL1QEk,5 1AX, <br />Mailing Address ►�R78 E Y (ZE # a9'? x,46-cox),4 ZEA<-ql, CA- '9a6J I <br />Dav Phone Number ( 7 14 ) 3 76 0422 (p <br />7— <br />Signature <br />Signature Title <br />EH 23 046 (Revised 7/10/96) Pale 6 <br />Date <br />