|
c.
<br /> ot An, Q!nx 01 lhlrq�oy cnryln� jos, to r
<br /> .- r r .,.
<br /> yro*rn, Ch
<br /> 'MmqTyna - !"k X—onno agetrj. .r.. . t th
<br /> b, -n u,u .,te #.
<br /> .., .. ,. ,., . .. . ,,t? ei! ! # ..-
<br /> 11 ., B.-" l �_. ,� e_`. a kJ r Ta. ,'�-
<br /> �: 1. royo [ C
<br /> 1
<br /> rT
<br /> t cg 4 M p k } £ -t n" c_ .FT.:i m .r wLi,.,,. 1,.. Mcite m w A a o W„ t used .,-J !- .,r`�� ,. __
<br /> pmunbris We Lmn Waited if
<br /> .. __ s t< Wrz.r,
<br /> veloWn, nwon, and address. Indicate whit€s party yco, >f1c ,
<br /> represent nt °n iri d co;'t a y of 1c CCOW41110 AWTOW_. sni l VWtHy We 1c block horizontal ornmixt
<br /> u, l� L ' s nave _....� 4 r . °r,r i' .�.# .,. .�,. , .�,.. Two" 3
<br /> _ and "a on of L7"e party sy..____......_
<br /> xrt,,, wool.1 norecil 7 M '` Ron m „';r' Lv 'W Y;.. Sol c`€ x twat n. ,: ,w .Z ae
<br /> -
<br /> Reonovr F ? c s r_,K�a_.. 3,�;zL�"ng 1. C.;act l.a#.. was..o",
<br /> S..i 1. . 'Af r _ _..m....-__�,....._.
<br /> k�t.L., TFE�zm__r.eei rogarding the =eek fadlity and su"a€.nAr_g area9 At ]Po Rol Inat �urr�il, el-vFed t,a ra ave dissolved
<br /> Ankionq San, o s t provide the facility rna nc ,and f.z' address,
<br /> Warned rE 9 F# C rr'tz� asc ad,!¢rn13;C ;:c E;,.J#yg to #,.;,r„zt
<br /> WI—EW?r _4G .xm �a dee., ,. i�t,,...:� t ,7 of
<br /> WA o,a. yal€:r Qnita,; Contra; Cemd kolaro S"Ay pmv de al lug ,ative water supply W afedLt �
<br /> ,� ”;?€..a,i, W .€,..✓4..:,3 T nst; !I water '"tt Lt,uT(t€.r v. devices at each dwelling or
<br /> _ SUHfUC .. >WrL%,, t fer glace of use,
<br /> rt r the ra Arad ,czantr y lost of t„rrr hazaM€ria sabsune involved. Rout is lo khon Bagnirp - inidpet is a no , requiring no
<br /> l'raass`ci d for „fofrr=.rtizn on No stzbst,s w; if ap r p,sate, if sio e than tomer
<br /> s bst:ance leakslist the two, of w�nt concern.,. r rJleanLdyr°
<br /> C E t C Use the space to Wlsoraw on any awn" of tw .
<br /> %# SCOV.R'f,,;B,'i MENT -Si to OKY Sign the ,.Y ,n in then spar rrev.Cle{3.
<br /> ra, ,>.e laratn`l tla ! scovery and aW Np=Q of Me leak.
<br /> SUR /l,,AUSE 1f the form is c ipdt:r.:f by top t nk owner or his agent, ro.tain 'R. i ist c"y
<br /> r,'' nNce<0 at Wak. Provide details on task n akaci y arc and inr°�ar the ra�°mi tnr, co �€sus in act M ynr Imal t k perG?rtr " agerF y
<br /> mat l if known,. Check books) ,n lcaMRg came of 'leak, for c atm r=t n
<br /> 1. Wain - 1oca' Tank ,ra,;n,"j" k+tierr.^.y
<br /> CASE YPE L SU" Wer Resumes Control board, Nv,_cierr of Water Qoal"y,
<br /> TT"-r .::. ur, .,..: x for We ?e<a"t.A Check one box c„€;r. Case :sr<. Ur.a,-Vr,ond Took F;oV , V V Box 1G , Sacrawasq 0 il.>MI
<br /> is based an then inost residue r€iso r'ce affected. For cxa-aiple, ;f both soil ;t l'r=ci,2njl Water, `,. -li+y Ccntrol n€arcl
<br /> and Vound mats, hao bee ralfect_d, case type will tin `Gr"Hn'N water - Ca,any Bear? of Sper0s°ors or Ciw1dgue. 'to receive Proposilvion 65
<br /> Irr 1 ita 1a inking Water” only if Ono or inare Hionicipal or di:onestic water noxificadono
<br /> wells Have ca,tullr bwo affected. A 'Gr an°a Water oes#r<"Von dws net 0"er,'regansih3e p"*.
<br /> W1 tela Me of ectid wat;or cannot hic, or, A not, osed for drirr bg water,
<br /> kt, only that water wells; have no yet bun afCs°nil. _ It Is rartrl:.rr;twd not,
<br /> case typo t fso'cta nv, ap"in further anvcstayatfo,
<br />
|