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06/13,`2006 14: 53 2094683433 <br /> EHD PAGE 07 <br /> 12, What is thr--depth to groundwater? — ,---- ---._-.-__ - — <br /> Desgdbe the source of informati= <br /> 13. Are there any water wells on this parcel ox adjacent properties? YES NO I <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. _. <br /> Private Well ft <br /> Irxi ationt Well ft, _ ... <br /> Monitoring Well ft_ <br /> C7ther �. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground x underground storage. tank(s)? <br /> YES[I Nod <br /> 15. Indicate the responsible party to be billed far additianal EHD staff time;expended beyond 3 hour <br /> minimum permit payment per tank. of the party desigttiated below is different than the permit <br /> applicant, e.g. property ownex, the party mn<st acknowledge this responsibility for the billing by <br /> signature and date below. <br /> Name!-01 <br /> Mailing Address V 1'1 � 14I)IM k) �_ S14W A <br /> Day Phone Number( <br /> Signature Title Dare <br /> EE 23 046 (Revised 3f9;06) 6 <br />