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2/20/2006 12:49 2094640136 ENVIRONMENTAL -ALTH PAGE 06/11 <br /> 12. What is the depth to groundwater? "S B ff7, <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [) NO[�}� <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft <br /> Irrigation Well ft. <br /> Et <br /> itorin Well ft. <br /> er ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? <br /> YES[)NOI] <br /> 15. Indicate the responsible party Lo be billed for additional EHD staff time expended beyond 3 hour <br /> minimum permit payment per tank. If the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by <br /> signs hue and date below. <br /> Name EnsPs-'Lo Ce rr�r~o <br /> Mailing Address Zs14 A. =-&L4 94—A. <br /> Day Phone Number <br /> ignature Title Date <br /> EH 23 046 (Revised 11/21/06) 6 <br />