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12. <br />13. <br />14. <br />15. <br />What is the depth to groundwater? <br />3 1 FC c1- w iV `ILo Qrr rd 1 O tAzo-. <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <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 />YES [I NO IK <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES&I"NO[ J <br />Indicate the responsible party to be billed for additional PHS-EIiD 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 5 -7 V,15'- 4::-2 C—In6,17` �u . 2316-3 <br />Day Phone Number ( S/ D ) S 7L - S b 0 <br />� (� C, -,,M .V_ <br />S ii Date 55 <br />Page 6 <br />