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N• <br /> SI'Z'E IDENTIFICATION FORM <br /> (Aaaeh addiilonal descripdon or explamdoo as needed.) <br /> Initial I.D. Follow-up Investigation (YnN): <br /> SITE INFORMATION _/4 <br /> Site Name: LALaX4E N2 c_X- L�v'E�s ro.e — c',7j?_t inn <br /> AKA: 5-ez� —got> <br /> SWIS #: r__�County:,s-A,_).-wAou.,.)Parcel #(s): Z6/.— IAfo — as <br /> Location: j s2" W. nQ�d/ E1c�L/aJ�► c <br /> `(1ne—Tilde LACAUon oe sp wiilri '""nip,moor,OM section.M 1r....1sp. <br /> Land Owner(s):—nfl4jer7gac,. 6f= C�fea a- S C—eyaAe✓AoeaeAz — <br /> Address: <br /> City: State:_----Zip: Phone: <br /> `types of Waste: inert, Res., Com., indust. 1.122. Liquid <br /> Site.Type' egal Dumping, Landfill, Burn Dum ,'�<e Treatment Unit <br /> Disposal Area (Acre): SWFP Date: WDR Numbeer: <br /> Dates of Operations: -�4, a3,eL 618 Closure Approved By: <br /> LAND USE ON OR WITHIN 1000 FT 1 MILE OF WASTE BOUNDARY <br /> Rural: No CYesjo <br /> Residential: Yes rNo Yes rt io) <br /> Commercial: Yea o Yet N <br /> Industrial: --Xe ._ yes <br /> Environmental Sensitive: o <br /> Water Supply Wells: (YeZ No esJ No <br /> Surface Water Bodies: NO o <br /> Inhabitable Structures: yu NNo <br /> Enclosed Structures: o <br /> Planned Improvements: Yea No Yes No <br /> OBSER'VAT'IONS <br /> Date of Field Visit: q3 Sig. Change Since Last Visit? (Y41—NA <br /> Surface Condition: � OLel e ycq� e, - 6s e& <br /> Landfill Gas: <br /> Leachate: <br /> Other: S..k yza cbR - e--`aa-fa i...._. uj A,, -6z,,,. LLnjL "10 <br /> • .Sr� . 30Z% WGA <br /> RECOMMENDATION <br /> Emergency Response: <br /> Other (e.g. smell aatle 11160 dumping thtt wutwta MWVk1):' <br /> Reassess Site? (Y/NINA): No Further Action? (D Priority Y": <br /> Priority for Site Assess t edrLow): . <br /> Prepared By: -& _Date: 47 q x:33 <br /> CLWMB Approval: ct► Compliance <br /> Cr#MB Cloture and ltemediadon Drench(Rev.3 MOM) <br /> Board Approved"M) <br />