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Department of Natural Resources FACILITY CONTACT FORM <br /> Form 3400-51 Rev.7-89 <br /> Date / /' <br /> ATTN. ' c'-I / '1 c�C. cj — 5.0D, ❑ PRETREATMENT WW2 6'. -� L _ I / <br /> M M D D y Y <br /> ❑ ENV.ENF.EE/5 ❑ MUNIC.WASTEWATER SECTION WW/2 Time(24-Hour Clock) <br /> f <br /> ❑ PRIV.WATER SECTION WS/2 ❑ IND.WASTEWATER SECTION WW/2 G ' <br /> � <br /> ' Contact Method <br /> ❑ PUBL WATER SECTION WS/2 ® _SD e?7 !Y/Z DISTRICT 17 In Person Telephone <br /> Facility Name J �7 Location (Address or 1/4-1/4) County <br /> 1,42;l. i YI< r<� S7ti 1<f C�. /4?r:5'%A /./ PeZYJ� <br /> Facility I.D.Or Wis.Unique Well Number WPDES Permit Number District No. DNR Person Making Contact <br /> Facility Representative Contacted Title or Position of Representative <br /> i rn I44.y%%r Ca/:c l, iv <br /> Activity Codes Representative's Telephone Number(including area code) <br /> _Le. - - - - - Z,57 -4.3/0 <br /> S'a /77 G a//e'd' 76 re/i/ c:-S/ C2 C 4l t77 <br /> it / <br /> .47'?/ /?///77c;/) /?... -///,--'1_571- 4 7;25-, �/7 <br /> /-/-7;/f/2/l /i? �"-;/ -`/c -71 /%1--'5.7-'r? <br /> 2 ' �,/ /F //(' -�' r=' �' l"ll".S//':s . /�'-' <br /> - T i2// dc- <br /> //Y./1/ /27-5/7M <br /> /71 Z -L r"� '.,d r""sk- e l 74r 7 <br /> de:t)/ t' //?�f s7C/ 1 11 <br /> ;%--e 7/1(/ 17 al(I i/'� /1��1C� �'l�i/ice i'1%/2;/ %elite;l <br /> (- . 6 �' rF-�%� Y" /'� �E?/7i'E'l7 11r lul l/ �l5/7? / <br /> /1,/,'//e 7-41,, 27— /*/1,-- / -3" e? ,S>e* <br /> C /le; d n : <( ec%C' ///.5V//S. /2/7-, r <br /> 77;p /711[,1/' CIf. C.? tCC%.s Z- <br /> ❑ Check if Additional Sheets Attached <br />