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SENSITIVE RECEPTORS SURVEY <br />.• site S ryg and Literature Research <br /> Store No: <br /> Location: ri6 r'2 G k:� _ lam. <br /> City/State„- S 4-ock+-oP1 <br /> ' I. Provide answers to the following questions: <br /> a. Is a public water supply well within 2500 ft? (yA <br /> If yes, Distance (ft) <br /> b. Is a private water supply well within 1000 ft? (y n) <br /> ' If yes, Distance (ft)_ a:Q2' ,s <br />• <br /> C. Is a subway within 1000 ft? <br /> ' If yes, Distance (ft) •- <br /> d. Is a basement within 1000 ft? (�n <br /> ' If yes, Distance (ft) <br /> e <br /> e. Is a School within 1000 ft? wt <br /> IP yes, Distance (ft) <br /> f. Is a surface body of water within 1000 ft? ( !7 <br /> If yes, Distance (ft) <br /> II. Describe type of ,Local water supply: <br /> Public <br /> *Supplier's NameS Q �+. lcJa�er Sys�e�, <br /> *Supplier's source�pyzd1:162 <br />• *Distance to Site _ •y .•• _ <br /> ' Private <br /> ill. Aquifer Classification, if available: <br /> ' Class 1: Special Ground Waters <br /> e Irreplaceable Drinking Water Sources <br /> Ecologically Vital <br /> Cuss 11: Current and Potential Drinking Water <br /> Class ITT. Not Potential Source of Drinking Water <br /> e <br /> .M . Describe observation wells, if any: <br /> ' Number <br /> Free Product (y/n) <br /> V. Signature of Preparer <br />