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12. <br />n <br />What is the depth to groundwater? N i701 <br />Describe the source of information: <br />11 <br />13. Are there any water wells on this parcel or adjacent properties? 'YES (I <br />NO pq <br />14. <br />15. <br />Public Well <br />M <br />Private Well' <br />fftL <br />Irrigation Well <br />Monitoring Well <br />ft. <br />Other" <br />pendingclosure be replaced with an aboveground or underground storage tank(s)'. YES[ l N®[ <br />Will the tank(s) l IJ } A <br />nimum <br />Ind'ecate the responsible party to be billefor <br />additional <br />below is different thantime <br />the perm,tappiic.ant, e.g. property owner, <br />permit payment per tank. If the party designated <br />ge this responsibility for the billing by signature and date below. <br />the party must acknowledge <br />Name '`!a 1 SS "� <br />Mailing Address2SOO <br />Day Phone Number ( 9)6v—) !p3 r <br />Signature <br />Page 6 <br />Ru <br />[1 <br />Date <br />