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12. <br />What is the depth to groundwater? 23 <br />Describe the source of information: <br />13. Are there any water wells on this parcel or adjacent properties? YES [ [ NO [e <br />TYPE OF WELLS <br />DISTANCE TO TANKS(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 />14. Will the tank(s) pending closure be replaced with an abovegroundor underground storage tank(s)? YES[ [ NO[ [ 'N/A - <br />15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum permit payment <br />per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />Name CAil�4 C-- PA '� C'PrF�• tom! A` )-i <br />Mailing Address k S iy - i�' C -Or-- .� v"S t�G �_ , oh•j CIA, -- <br />Day Phone Number ( 2.0"? ) 2-+b " <br />11 � <br />Signature Title Date <br />EH 23 046 (Revised 08/13/99) Page 6 <br />