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10/17/2000 09:60 2094683433 <br /> FIFTH FLOOR PAGE B5 <br /> �2 What is the depot to groundwater? <br /> ht�escme the scum of Wermatioj vl t Y C-_ � �� <br /> 13 Are there any w$#er wellsan ttds psreel or aglaeeut p"pertlesZ <br /> YESi1 SO[1 <br /> TMIVWUU MANOR TO TARM" <br /> Public Wel <br /> Private Weil fL <br /> Woe Wen it. <br /> Mont to WeR ft <br /> Otber f<. <br /> i4. Wfll the tank(8)pendlug d0sure be replaced vfM an sbavegntmd or mduVOUM storage tagXs)?ygR 1 N01 I <br /> Indicate tits r'esponslbie party%G be billed for adslftlonal PR&R D staff tame expestded beyond 3 hoar mum <br /> Pr ftnX If the parte desfgaated below is different than the peru t applie petuC]t pspment <br /> O " <br /> respaaei6MI'Or toe bi1ft by SIPAUme Bad date below �4 e.@,:�°De Y o�+ar,the party mit xe>�otoiedge <br /> Nutae <br /> 'dal Lr Address <br /> Day phone ITIMber � <br /> 8igxtatin— Tine <br /> nate <br /> 046(Rcvmed 08/13/99) Page 6 <br />