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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. t k(s)pending closure be replaced with an abovegr r underground storage tank(s)? YES[]NO[] <br /> 15. Indicate the responsible party to be billed for add' HD staff time yond 3 hour minimum <br /> permit payment per tank. If the party designat w is different than pplicant,e.g.property <br /> owner,the party must acknowledge this resp ity for the billing by ture a date below. <br /> Name <br /> Mailing Address <br /> Day Phone Number <br /> Sign Title Date <br /> EH 23 046 (Revised 12/31/07) 6 <br />