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12. <br />13. <br />14. <br />15. <br />What is the depth to groundwater! <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WE[1S <br />I DISTANCE TO TANKS(S7 <br />Public Well <br />ti. <br />Private Well <br />M <br />Irrigation Well <br />M <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />YES [I NO k <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YESX NO[ <br />Indicate the responsible party to be billed for additional PHS -EBD stair 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 A4"`- L-kk--, f &jb-L—yj N <br />Mailing Address +a &Ai t— Syo W - AL3 U)W &VF C4eisF:l - . e n , 9-4�C16, <br />Day Phone Numbed ( 0 ) 9 �3>0 S % -) <br />Page 6 <br />/ <br />/J (a <br />b <br />Da <br />