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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 [] NOL <br /> TYPE OF DISTANCE TO <br /> WELLS TANKS(S) <br /> ZPubhcWellEa <br /> 14. Will the tank(s)peg closure be replaced with an aboveground or underground storage <br /> tank(s)?YES[] NO <br /> 15. 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 /> MailingAddress <br /> Day Phone Number( 2�`� ) `l 3 > �/16� 9S ZV Z <br /> PVD A� �e►- <br /> l � Dec • 2• 2oa <br /> Se Title Date <br /> EH 23 046(Revised 3/15/02) Page 6 <br />