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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 WEUS DISTANCE TO T4NKS(S7 <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)?Y 'NO[ ] <br /> 15. Indicate the responsible party to be billed for additional PHS-EED 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 <br /> Mailing Address 124--3 A ak/L �ebAQ C- ,L. 459, <br /> Day Phone Number (Q - C���7 FA X (,5(o) 2-3:3�-Q5_ <br /> IL <br /> gnature Date <br /> Page 6 <br />