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10/17;2000 09:00 209468: FIFTH FLOOR PAGE 06 <br /> 12 What Is the depth to groundwater? 1'n C f �.' 'f^ <br /> Describe the sooree of information <br /> 13. Are there any water webs on this parcel or adjacent propertles? �!1 No u <br /> TTPL IV WUU B19TANCE TD TAMUM <br /> Public Weil ft <br /> Private WeR fL <br /> don WeR h, <br /> elordtorto WeN tt <br /> Other g, <br /> 14 Will the tanks)pending closure be replaced with an abovegromid or nndervanad sturage eak(s)?YS8(<)NO[1 <br /> 15. indicate the respeaMie parry to be billed for additional PHS-HHD staff time expended beyond 3 hour-W um permit payment <br /> per tank. V We pasty destuted below Is dbffereut than the permit appltcaM,e.g_property owner,the party mst acknowledge <br /> this reepansibmty for toe Mg by algnatare and date below. <br /> Name MASON CFNTFR LIC <br /> MalIMEAddress P . 0_ Box 9978 IIANVTI LF fA 94526 <br /> Day Phone Number( q 2 ry_I_9 R R_n 2 n n <br /> Signature Tine Date <br /> EH 23 046(Revised 08113199) Page 6 <br />