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AlOr ''fi n -s <br /> SENSITIVE RECEPTORS StAMEY - <br /> .SL to Surr_eand Literature Research <br /> Store No. #///W <br /> Location (p � <br /> Ci ty/State , CO ,)Wm,•% <br /> I. Provide answers to the following questions: <br /> A. Is a public nater supply well within 2500 ft.? <br /> If Yes, Distance (Ft.) A-4 <br /> B. Is a private tinter supply well within 1000 ft.? <br /> If Yes, Distance (Ft.) z.ode Ae-e- <br /> C. Is a subway within 1000 ft.? (Y� <br /> If Yes, Distance (Ft.) <br /> 0. Is a basement within 1000 ft.? (YO <br /> If Yes, Distance (Ft.) <br /> E. Is a School within 1000 ft.? (Y.0 <br /> If Yes, Distance (Ft.) <br /> F. Is a surface body of water within 1000 ft.? (Y&1 <br /> If Yes, Distance (Ft.) - <br /> II. Describe type of local water supply: <br /> Public <br /> - Supplier's me <br /> ,'Naa <br /> - Supplier s Source �� c <br /> - Distance to Site w <br /> Private III. Aquifer Classification, If available: <br /> Class Is * 'Special Ground Waters <br /> -� Irreplaceable Drinking Water Source <br /> Ecologically Vital <br /> Class II: Current and Potential Drinking Water Source <br /> Class III: Not Potential Source of Drinking Water <br /> IV. Describe obsejrvati on wells, If any: Number <br /> Free Product (Y/N) <br /> V. Signature of Preparer Date <br /> OI54bpc5 <br />