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AMML <br />S* IDENTIFICA'TION FOW <br />(Attach additional description or explanation as needed.) <br />Initial LD4Follow-up Investigation (Y/N).- <br />0* - IM <br />MAMM"AdVA <br />AKA: <br />SWIS #: County: S <br />Loca r_Me4 ./_4-i-zq -ris 46E 1,4-M <br />cu C auoa or us - ap w, Ow IP, 090, anct Section, and Parcel map.) <br />L.andOwner(s): <br />Address: <br />City: Abe�t A2111-64 4,,,ujtate: I -Q> zip:2-toto- -Phofie:-, <br />Types of Waste: Inert, Res., coig. Indust., Haz. Liquid <br />LdffUwl <br />n um urDc4 <br />Site. Type: Illegal. Dumping, L reatment Unit <br />Disposal Area (Acre):_ SV-,rFP D AJO R Num <br />Dates of Operations: ej_qS_-,-b_ -jrJ,716 -Closure Approved By: PT -<x--- ewigag <br />LAND USE ON OR VaTEOIN 1000'FT 1 MILE OF WASTE BOUNDARY <br />Rural: <br />Residential: <br />Commercial: <br />Industrial: <br />Environmental Sensitive: <br />Water Supply Wells: <br />Surface Water Bodies: <br />Inhabitable Structures: <br />Enclosed Structures: <br />Planned Improvements: <br />d1�sf- Of l . <br />Date of Field Visit: Sig. Change Since Last Visit? A <br />Surface Condition: d r1If 69 C'P_ r"Ied <br />Landfill Gas: <br />Leachate: <br />Other: <br />Emergency Response: <br />Other (e.g. small scale illegal dumping that warrants removal): <br />Reassess Site? (Y/N/NA): No Further Action? (D priority Y/N):---,---- <br />Priority for Site Ass s ent? ed/Low): <br />Prepared By: ) C 2_6 _ Date: q _2 <br />- rz� k (d <br />CIWNM Ai6povar- C'&RJAa;ch Compliance <br />CrWM3 Closure and Remediation Branch (Rev. 3710193) <br />Board Approved (2/25M) <br />