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81r IDE FICA"ON FA <br /> (Attach additional description or explanation as needed.) <br /> Initial I.A. (YIN): Follow-up Investigation (YIN): <br /> SITE INFORMATION <br /> Site Name: <br /> A.K.A.: h �,Parcel As): Y 9 - 0 �o -t 3 <br /> SWIS #: County: S _U� .e - <br /> Location: c 113391 aeon or us sp wi ownship,Range,2111 section,&no ParcelaP• <br /> Land Owner(s): L-Z,j �_d <br /> 02 3 D�- 3 �4-c� Vie. Ae� <br /> Address: � <br /> City: 2r'vei-4�� State: C __Zip: 9 3io ? phone: <br /> Types of Waste: Inert, <br /> Res., Com., Indust., Haz., Liquid <br /> Site.Type: Illegal Dumping, Landfill, wpm Du p, Treatment Unit <br /> Disposal Area (Acre): SWFP Date: WDR Number: <br /> Dates of Operations: Closure Approved By: <br /> LAND USE ON OR WITHIN1800 FT 1 MILE OF WASTE BOUNDARY <br /> Rural: ".Yes <br /> Residential: <br /> Commercial: <br /> Industrial:Environmental Sensitive: <br /> Water Supply Wells: <br /> Yes No Y N <br /> Surface Water Bodies: Yes o Yes No --v <br /> Inhabitable Structures: es No es No <br /> Enclosed Structures: es No Yes , No <br /> Planned Improvements: <br /> Yes No Yes No <br /> OBSERVATIONS <br /> Date of Field Visit: 'Y� � Sig. Change Since Last Visit? (Y A): <br /> Surface Condition: <br /> Landfill Gas: <br /> Leachate: <br /> Other: <br /> RECOMMENDATION <br /> Emergency Response: <br /> Other (e.g. small scale illegal dumping that warrants removal):* <br /> Reassess Site? (YIN/NA): No Further Action? (D Priority YIN): <br /> Priority. for Site.Assessment (Hig�ed/Low): <br /> Prepared By: Date . <br /> Compliance <br /> C Approval: C&R Branch <br /> 0 <br /> C"B Closure and Remediation Branch(Rev.3710193) <br /> Board Approved(2/25/93) <br />