Appendix C - Hazardous Facility Screening Procedure Attachment C1 Site Information Form Item Information Facility Name Address Map Reference Description of activity Nature of adjoining land use Proximity to potable water resource23 Within 20 metres of a waterbody4 Map of Site (Show adjoining land uses and location of waterbodies) 2Groundwater reservoir/aquifer as identified by the council 3 ‘Waterbody’ includes streams, springs, lakes, wetlands, sea and estuaries, but does not include aquifers and entry points to the stormwater drainage network. App C - 11