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i <br /> 12. 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 ( ] NO ( <br /> TYPE OF WELLS DLSTANCE TO TANKS(S) <br /> Public Well ft <br /> Private Well it <br /> Irrigation Well ft. <br /> Monitoring Well It <br /> Other it, <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES [ j NO( j <br /> r additional PHS-EHD staff time expended beyond 3 hour minimum <br /> 15. Indicate the responsible party to be billed fo <br /> permit payment per tank. If the party designated below is different than the permit applicant, a g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name <br /> Mailing Address - <br /> S . i <br /> Day Phone Number ( - ) - - <br /> > _ 7` e ✓ <br /> Signature Title Date <br /> EH 23 046 (Revised 9/ 11/96) Page 6 <br />