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tfL <br /> 12. What is the depth to groundwater? 6to <br /> Describe the source of information: A Y 4 '' 1^(N� d tyJ -Qrrl �I � p„�f��•-'` <br /> 13. Are there any water wells on this parcel or adjacent properties? YES)K NO[) <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft• <br /> Private Well ft• <br /> Irrigation Well ft. <br /> Monitoring Well 1 0 ft. <br /> Other ft. <br /> 14. Will the tank(s)pending Closure be replaced with an aboveground or underground storage <br /> tank(s)?YES[] NCK <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 /> r <br /> Name ! Y i ►�J <br /> "odMailing Address i �� f© f <br /> Day Phone Number( 6 ) l ! <br /> Signature Title Da <br /> EH 23 046(Revised 10/16/03) Page 6 <br />