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a1• <br /> SITE IDENTIFICATION FORM <br /> (Atueh&ddidodel desetipdon or explanadon at needed.) <br /> Initial I.D.6�0: Yes Follow-up Investigation (Y/1): <br /> SrM MORMATION <br /> Site Name: Lj4r.✓ZE^2cji5 Lr v'E.0 Aew e,E — rt 72E --3d,5n <br /> AKA: l cz- –4oa <br /> SWIS #• —County-,s.4.J mA nout–)Parcel #(s): •2.S/.— /'fo – o-, <br /> Location: ul g:;Q"44Ald n J 0-A .TL°.A J <br /> e LEce"On or uamop WNWOWMM p x ageMSecaon.an area map.) <br /> Land Owner(s):�UAfxV_ r�,.r--of C�Jf tt?.✓Aeg^,T <br /> Address: <br /> City:._ State' Zip: Phone: <br /> 'types of Waste: inert, Res. Com., Indust., Hat. Liquid <br /> Site.Type: gal bumping, Litndfill, Burn Dump, r ttnlent Unit <br /> Disposal Area (Acre): 'y/"''`�7� SWFP Date: WDR Number: <br /> Dates of Operations: tqio ---Closure Approved By: <br /> LAND USE ON OR WrMIN 1000 FI' 1 MILE OF WASTE BOUNDARY <br /> Rural: o <br /> Residential: Yes _ es o <br /> Commercial: Yea 'es <br /> Industrial: o <br /> Environmental Sensitive: No <br /> Water Supply Wells: o } es <br /> Sur&ce Water Bodies: es o es <br /> Inhabitable Structures: N <br /> Enclosed Structures: es o <br /> Planned Improvements: Yes No Yes No <br /> O$SERVA'I'IONS <br /> Data of Field Visit: y /& '?J Sig. Change Since Last Visit? (Y/1A :) <br /> ) <br /> Surface Condition:,.� �J coir.c Q � ��a' ,._- �•i <br /> Landfill am: <br /> Leachate: <br /> Other: <br /> RECOMMENDATION <br /> Emergency Response: <br /> Other (e.g. smell sWe illegil dumpidg that wtl anis tetnovil):' <br /> Reassess Site? IN I" <br /> No Further Action? (D Priority Y": <br /> Priority for Site Assess t ed/low): <br /> . . <br /> Prepared $y: -� Date: 4 r.3 <br /> CrMM Approval: ch Compliance <br /> CrWMB Closure and Ren edladon Branch(Rev.410M) <br /> Board Approved(1!2!/99) <br />