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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 properties? YES [ ] NO W <br />TYPE OF WM.IS <br />I DISTANCE TO TANKS <br />Public Well <br />)C�o I- ft. <br />Private Well <br />/&Q 4- ft. <br />IrrigationWell <br />LeL +- m <br />Monitoring Well <br />/00 q-- VL <br />Other <br />ft. I <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ I NO[IK <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 C"--�V -) c'� S <br />Mailing Address 2-/'7-2 <br />Day Phone Number( 2 061 <br />01g114LU1 V <br />Page 6 <br />Date <br />