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Continued from Page 1. <br /> Lowest Adjacent <br /> Address Lot Number Block Number Lowest Lot Grade To Base Flood BFE Source <br /> Elevation* Elevation <br /> Structure <br /> This certification is to be signed and sealed by a licensed land surveyor,registered professional engineer,or architect authorized by law to certify elevation <br /> information. All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false statement may be punishable <br /> by fine or imprisonment under Title 18 of the United States Code,Section 1001. <br /> Certifier's Name: License No.: Expiration Date: <br /> Mark E.Krause PLS#1808-8 01/31/2024 <br /> Company Name: Telephone No.: <br /> Wagner Surveying Associates,Inc. (715)866-4295 <br /> Email: Fax No. <br /> coleen.wagnersurveying@gmail.com (715)866-4206 <br /> Signature: Date: <br /> *For requests involving a portion of property,include the lowest ground elevation within Seal (optional) <br /> the metes and bounds description. <br /> Please note:If the Lowest Adjacent Grade to Structure is the only elevation provided,a <br /> determination will be issued for the structure only. <br /> DHS-FEMA Form 086-0-26A,FEB 11 Elevation Form MT-1 Form 2 Page 2 of 2 <br />