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PNS/.JWOUIN COUNTY - ENVIRONMENTAL HEALTH OIVL ` <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / / /,BY: Lt%� REVIEVEDI By: DATE ENTERED: (� <br /> SLEEPS/SITE CODE ���} 43i ( PROGRAM/ELEM`EN'T „/ 3 I Comp x IVI LOC CODE D , DIST x <br /> UGT FILE X PILOT FILE N V FILE X `S�f TE MITI WTION PVS FlL"e PRIV WELL FILE ENV ASSESS <br /> SOLID WSTE H2O 0 FILE EPI FILE/ ` LAND USE FILE OiNER AGENCY REPORT EMERG'cNCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EN CONTACT IIS r v DNS CONTACT �' ,a41,",_(_rb <br /> OTHER CONTACT RVOCS CONTACT VAR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONT ' _ GV CONT DV CONT ETROLEUM Y / N <br /> SUBSTANCE 01 / D 3 & 02 x3 x4 x5 <br /> PRICR FAILED PT NO ACTION CLEAN UP COMPLETE DATE /ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE:G) 2 3 4 S 6 DATE ACTION TAKEN: <br /> SITE NAME -� --�-S <br /> Th <br /> ADDRESS / C'Q�C�C..CJLJ <br /> CITY SI (,'G_ ��C� 1ij� STATE ZIP Q JD <br /> CONTACT NAME �' W/ u Iti�cY G PRONE (p�7- <br /> PRCPEtTY OWNER <br /> PHONE <br /> P§94 <br /> — <br /> PHONELimt W`�� '� ��/-��U STATE C�' ZIP <br /> RESPONSIBLE PARTY (If different from Property Ov r) <br /> /• ' PHONE <br /> COMPANY NAME <br /> PHONE <br /> CONTACT NAME <br /> ADDRESS 1 ' <br /> CITY STATE ZIP <br /> PHONE <br /> CONSULTANT <br /> UAR x DATE PROP 65-0 93-�i DATE F-I 0PAPNO <br /> PRICR`I7TY ''][y <br /> STREET x S S SITE STREET /(, r !'�D 17 �" (-� <br /> EH 23 C70 (7/B9)REVn SED 03191 39-19(IV) CNTMFR2 <br />