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I L 1,4 I i_I i !L I kj _ _ _ - <br /> SF-NSITrVE RECEPTORS StMVEY <br /> If re ]research <br /> Site SU—MreY _�il� <br /> F <br /> !' store No-_ 11195 <br /> Location: Ly s <br /> city/stat FCry- f <br /> ' Provide answers to the following questions: f <br /> a. Is a 'public water supply well within 2500 ft? (Y <br /> yes,es, Distance (ft) <br /> b. zs $ private water supply well within 1000 ft? (Y n) <br /> ]Cf <br /> yes, Distance (ft)- <br /> C. Ts a subway within 1000 ft? &n <br /> If yes, Distance (ft) <br /> d` Is a b$ ement within 1004ft? <br /> rt <br /> If yes, Distance (ft) <br /> �L <br /> ftp (YO <br /> e; Is a school within 1000 <br /> If yes, Distance (ft) <br /> Is a surface body of water within 1000 ft? (" ' <br /> It yes, Distance (ft) <br /> I s II. Describe type of local rater supply: <br /> ' c <br /> *Suppl ier 5 dame - <br /> *Supplier Is Source '. �'►� operallan <br /> *Distance to Site .___ .•�; <br /> Private <br /> Aquifer Classification, if available: <br /> class l: Special Ground Platers <br /> irreplaceable Drinking Water Sources <br /> Ecologically vital <br /> =i Class II: Current and Potential Drinking Water <br /> Class .Ixx: Not Potential Source of Drinking Water <br /> :Iv4r- Describe obsen,ratior Walls, zip any: <br /> Number <br /> j :� ;F. -. • Free Product .�(Yf h) <br /> a <br /> 4: 3 V. Signature of Preparer -'. ^-�' •� Date! <br /> i1 I <br /> 1- <br />