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v <br />12. What is the depth to groundwater? f'ro , <br />Describe the source of information: <br />11 <br />13. Are there any water wells on this parcel or adjacent properties? YES WfO [ ] <br />TYPE OF WELLS <br />DISTANCE TO T <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 aboveground or underground storage tank(s)? YES[ ] N <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 />Mailing Address 2epOO/ G/ i`99 SZ: ZZAAJDAO df IV 44-7 i <br />r <br />Day Phone Number 5-/0 Ca / <br />Signature � Title Date <br />EH 23 046 (Revised 08/13/99) Page 6 <br />