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05/30/2003 16: 36 2094683433 FIFTH FLOOR PAGE 06 <br /> 12. What is the depth to groundwater? ri <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [] NO [q <br /> TYPE OF DISTANCE TO <br /> WELLS TANKS(S) <br /> Public Well ft_ <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft_ <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage <br /> tank(s)?VESA NO[) <br /> 15. Indicate the responsible party to be billed for additional EHD staff time expended beyon.d'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 /> G(Anel2 �vu�� ,2cs�w�e��•al Seoutce5, 7:r►vc , <br /> Mailing Address <br /> Lf Ll oto 12ys5e!/ knn6ao 50,�c A. MLjk, I ieo� (jJA %F-70— <br /> Day Phone Number( LI Z S ) 3ds- Z$Z Co <br /> ;1�� 0t-+A?1941(246 <br /> Signature Title Date <br /> EH 23 046(Revised 3/15/02) Page 6 <br />