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{�12. What is the depth,to groundwater? <br /> Describe the source of information: <br /> i <br /> I3. Are there any water wells on this parcel or adjacent properties? YES NO[] <br /> MELLS DISTANCE TO TANKS(S)'� g. �9(J�ll �. <br /> 14. Will the tank(s)pending closure.be replaced with an aboveground or underground storage tank(s)? YES[]NOX <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 /��'G � �Uc�l�l ' l ���Ji✓ <br /> Mailing Address Q. JoX7`'(�►j �`�f. y S <br /> Day Phone Number <br /> Si na re <br /> _ - Title <br /> Date <br /> r <br /> EH 23 046 (Revised 07/31%08) 6 <br />