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i <br /> NOA Project Number: E04046A <br /> Page 4 <br /> 14. Identify any surface waters on the subject property within 1,000 feet. <br /> Mormon Shxgh demes the sowbern boundary of the sxbjectpmper* <br /> 15. Is there evidence that the subject property is serviced by a private well? <br /> Yes a No <br /> ` Evidence of a private well within 1,000 feet? <br /> L Yes Q No El <br /> 16. Identify the potable water supply source: <br /> None <br /> P 17. Identify the sewage disposal system: <br /> L None observed <br /> 18. Are there any pits,ponds,or lagoons located on the property in connection with waste <br /> treatment or waste disposal? <br /> Yes Q No m <br /> 19. Is there evidence that the subject property discharges waste water, other than storm water, <br /> L directly into a ditch or stream on or adjacent to the property? <br /> Yes Q No m <br /> Any discharges within 200 feet? <br /> 1. <br /> Yes[:] No m None obse ved <br /> y 20. Is there evidence of underground/aboveground storage tanks on the subject property? <br /> L <br /> Yes[:] No m <br /> Within 200 feet? <br /> Yes[:] No m <br /> L 21. Are there any vent pipes,fill pipes,or access ways indicating a fill pipe protruding from the <br /> ground on the subject property? <br /> LYes[:] No m None observed <br /> Within 200 feet? <br /> Yes m No None observed <br /> L <br /> "004 <br /> L <br /> L <br />