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1W Y <br /> 12. What is the depth to groundwater? w Gs <br /> Describe the source of Information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES (] NO(}� <br /> i <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well a tt <br /> i <br /> Private Well 1t. <br /> Irrigation Well tL <br /> Monitoring Well ft <br /> Other rL <br /> 14. Will the tanit(s)pending closure be replaced with an aboveground or underground storage tank(s)?YES[J NO{j <br /> 15. Indicate the responsible party to be billed for additional MEHD staff time expended beyond 3 hoar minimum permit payment <br /> per tank. If the party designated below is different than the permit applicant e.g.property owner,the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> Name U I hlGe—; t <br /> Mailing Addressi 0 f X41 c500 rac Tta� W <br /> Day Phone Number( <br /> )C 3- 1Z - o 1 <br /> Signature OU Date <br /> EH 23 046 (Revised 10/19/98) Page 6 <br />