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Com: <br />lz What Is thedepth to groundwater? <br />Describe the source of Information: <br />13. Are there any water wells on this parcel or adjacent properties? YES () N0 <br />Oil "11 ,,1 '=—DISTANCE <br />TO TANKS(S) <br />I- <br />14. Will the s) pending closore be replaced with an aboveground or underground storage s)? ) NO <br />15. Indicate the responsible party to be billed for additional staff time expended beyond 3 hour min ermit payment <br />per tanlL If the party designated below Is different than the permit applicant, e.g. property owner, the party must aclmowledge <br />this responsibility for the billing by signature and date below. <br />Name —\ A\ i (4- k -, cm) r \ A <br />Mailing Address Z.�o 5,LvL:�,, aUCoy5-14Z <br />Day Phone Number <br />GYy IZ 2 8 Lc t i F'u2 01\Nt1� <br />Signature Title Date <br />EH 23 046 (Revised 10/19/98) Page 6 <br />