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OTE IDENTIFICATION %M <br /> (Attach additional description or explanation as needed.) <br /> Initial I.D. (Y/N): Follow-up Investigation (Y/N)e <br /> SITE INFORMATION <br /> Site Name: -5p, de-r i Sumq <br /> AKA: <br /> SWIS #: County: Cdvnj�r Parcel #(s): <br /> Location:34.,A, 9 AA m° dw1 aF '!; <br /> cue Locauda or Quad.Map with ow ip,Range,and Sw-tion,an arca tip. <br /> Land Owner(s): <br /> Address: <br /> City: State: Zip: Phone: <br /> Types of Waste: -Inert, es. Coln., Indust., Haz., Liquid <br /> Site.Type: Illegal Dumping, dfill urnPR; Number: <br /> Treatment Unit <br /> Disposal Area (Acre): >•SWFP Date: ,v/,� k14 <br /> Dates of Operations: Closure Approved By: 1,4 <br /> LAND USE ON OR WIT'ELCN 1000 FT 1 MILE OF WASTE BOUNDARY <br /> Raj: No No <br /> Residential: No No <br /> Commercial: Yes No es No <br /> Industrial: Yes c es No <br /> Environmental Sensitive: Yes No Yes No <br /> Water Supply Wells: Yes No No <br /> Surface Water Bodies: es Yes No I//Z-AAr <br /> Inhabitable Structures: Yes No es N <br /> Enclosed Structures: Yes o Yes • No <br /> Planned Improvements: Yes Yes -do)- <br /> OBSERVATIONS OBSERVATIONS <br /> Date of Field Visit: t4 -1 A Sig. Change Since Last Visit? (Y/N/NA): & <br /> Surface Condition: QuA 'a�4- tuf tumi=S e A I g af° tag.46& ------ <br /> s le ,� 0 ® - <br /> Landfill Gas: A& <br /> Leachate: �t0/ <br /> Other: nom' A g,11 <br /> RECOMMENDATION <br /> Emergency Response: <br /> Other (e.g. small scale illegal dumping that warrants removal):' � <br /> Reassess Site? (Y/N/NA). ND-Further Action? (D Priority Y <br /> Priority for Site,Assessment (HighiM w)• <br /> Prepared By: Date: S '-r- <br /> CIW1s1B Approval: Bran h Compliance <br /> CIMM Closure and Remediation Branch(Rev.3710193) <br /> Board Approved(?125193) <br /> i <br />