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05/30/2003 16:36 2094663433 <br />12. What is the depth to groundwater? <br />13. <br />14. <br />15. <br />Describe the source of information: <br />(VO <br />FIFTH FLOOR <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF <br />WELLS <br />DISTANCE TO <br />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 />• <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage <br />tank(s)?YES Eq NO[ <br />PAGE 06 <br />YES [] NO[] <br />Indicate the responsible party to be billed for additional 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 <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name <br />�'ew <br />lac��2 �0„zor�,l,o <br />,-vm.,�( Scjzyicrs, Zrr.)C <br />Mailing Address <br />e-lgt& Iwssr <br />Day Phone Number <br />Signature Title Date <br />EH 23 046 (Revised 3/15/02) Page 6 <br />73 <br />