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1] <br />12. What is the depth to groundwater? ' t 15- 0]' <br />Describe the source of information: <br />13. Are there any water wells on this parcel or adjacent properties? YES [ ] NO <br />TYPE OF WENS <br />DISTANCE TO TANKS(S) <br />Public Wellr.{- <br />Private Well <br />ft., <br />Irrigation Well <br />R <br />ft. rt t. <br />Monitoring Well <br />ft. <br />Other <br />R <br />fit. +- <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO[ ] <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name 5CJ-VV �jC�9c .A�n �f9 V+�+"� ) <br />Mailing Address �'i�1'�l 4 • wl lesq✓< <br />Day Phone Number ( ) 3 1 b(0 <br />Signature <br />Page 6 <br />S C Ls <br />Dat <br />