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�J <br /> *a- <br /> SITE IDENTIFICATION FO <br /> (Attach additional description or explanation as needed.) <br /> a <br /> Initial I.D. (Y/N): t� [ q3 Follow-up Investigation (Y/N): <br /> SITE INFORMATION <br /> Site Name: E l!�IPO c. e i- <br /> AKA: -- <br /> SWIS #:_ County: Parcel #(s): g 3 °� 2 `� —0 <br /> a fi o ., <br /> aW4AQi j rK c/ ��f e / s. �=r c� c a ,ra -5_3'-75- <br /> Location: <br /> ac u a anon or uamap w1i A o as6ip,Mange,and section,and ParcelMap.) y vG J ( /7,Ce' 4¢] <br /> Land Owner(s): �-, <br /> Address: f 3 iAI I f,IV) ��s� d .sem�,� �r o 5_i0 6 7i 3�70 <br /> City: tate: Zip: q Ys�v Phone: s®o - & -7 -7a <br /> Types of Waste: •Inert, Res., Com., Indust., Haz: Liquid <br /> Sim.Type: Illegal Dumping, Land ,-' Burn Dump, Treatment Unit <br /> Disposal Area (Acre):' acteSWFP Date: WDR Number: <br /> Dates of Operations: Closure Approved By: <br /> LAND USE ON OR WITHIN 1000 FT 1 MILE OF WASTE BOUNDARY <br /> Rural: es No � No <br /> Residential: No No <br /> Commercial: Yes oes No <br /> Industrial: Yes o No <br /> Environmental Sensitive: es No No VCvN <br /> Water Supply Wells: Yes No Yes No <br /> Surface Water Bodies: Yes 40 Yes _ <br /> Inhabitable Structures: Ces No No <br /> Enclosed Structures: es No • No <br /> Planned Improvements: Yes No Yes No t K ^^ •1 <br /> OBSERVATIONS <br /> Date of Field Visit: Go 4 J dL Sig. Change Since Last Visit? (Y A): <br /> Surface Condition: ` <br /> Landfill Gas: /ox- <br /> Leachate: C:°®r Ir"Q,v� Woe-, e7 /` / � <br /> Other: <br /> CO ATION <br /> Emergency Response: AU <br /> Other (e.g. small scale illegal dumping that warrants removal): <br /> Reassess Site? /NA): No Further Action? (D Priority <br /> Priority for Site assessment (High/Med/J&: <br /> Prepared By: ----Pate: <br /> • C Approval: C&R Branch Compliance <br /> CrWMB Closure and Ratnediation Branch(Rev.3710193) <br /> Board Approved(2!25!93) <br />