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12. What is the depth to groundwater? VA Lk � <br />Describe the source of information: <br />13. Are there any water wells on this parcel or adjacent properties? YES [I N0 <br />TYPE OF WELLS <br />DISTANCE TOT 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 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 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 L,• / _ <br />Mailing Address S 5 f - f 7�. 7 0 � oT> 1, <br />Day Phone Number <br />Vo <br />Signature Title Date <br />EH 23 046 (Revised 10/19/98) Page 6 <br />