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L N..00 <br /> 12. What is the depth to groundwater? Unknown by contractor <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [[ N0]( <br /> M <br /> S DISTANCE TO TANES(S) <br /> n•n•n•ell ft.n- <br /> 14. Will the tank(s)pending closure be replaced with an aboveground at 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. / - r p <br /> Name k 1�r�yJ tZ�( <br /> � � /-t.. &4c V c �'`'1 1 . ►�k ftp v►it�V t$� <br /> Mailing Address X � 1 <br /> )k Day Phone Number( I ) t 3 3 2 C) <br /> Signature Title Date <br /> EH 23 046 (Revised 08/13199) Page 6 <br />