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12. What is the depth to groundwater? <br />61 <br />Describe the source of information: 6 <br />13. Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />DISTANCE TO TANiiCS(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />YES [) NO fid <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 <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name 21l-\ : n 1 <br />Mailing Address 192:f'Day Phone .E��►S�l�t��il,�:��it�►��a�,•����..������ <br />Number �t , <br />pe, <br />Title <br />EH 23 046 (Revised 9/11/96) Page 6 <br />7 <br />Date <br />5/'in i9$ <br />