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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 propertles? YES NO <br /> TYPE OF WEUS DISTANCE TO TANKS(S) <br /> Public Well <br /> Private Well VL <br /> Irrigation Well <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)? 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 <br /> Mailing Address <br /> Day Phone Number <br /> Signature Date <br /> Page 6 <br />