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PNS/Sor,IOACUIN CCUNTY - ENVIRONMENTAL HEALTH OIVtS. <br />CONTAMINATED SITE 0-Sase MFR - INPUT FORM <br />Rr� REVIEWED BY: DATE ENTEREO: BY: <br />SUE EPS/S(7E CODE <br />L/ U. <br />PROGRAM/ELEMENT <br />`� 3 J�Z) <br />COMP Y <br />131 0 <br />LOC CODE <br />U <br />DIST <br />/JPn �GL C <br />UGT FILE <br />PILOT FILE <br />STATE <br />X W FILE <br />Y / N <br />SITE MITIGATION <br />Y / N <br />PWS FILE <br />PRIV WELL FILE <br />ENV ASSESS <br />STATE <br />SOLID WASTE <br />ZIP <br />X20 0 FILE <br />EPI FILE <br />LAND USE FILE <br />OLHER AGENCY REPORT <br />EMERGENCY RE570NSc' <br />LEAD AGNCY/UN IT <br />(� <br />AOORESS <br />WEN CONTACT <br />CITY <br />p STATE C4. ZIP }5 )O`/ <br />DHS CONTACT <br />- - <br />OTHER CC <br />/JPn �GL C <br />PHONE <br />R%AC3 CCNTACT <br />STATE <br />WOR issued <br />Y / N <br />NPOES issued <br />Y / N <br />FAILED PT SOtL CONT/g� GW CCN7 DU CONT ETRCLEUM T / N <br />SUBSTANCE.1 /�_ ���/3�-- �2 I �pb'�'cY�13 XS <br />iRICR FAILED PT �=R-N£O�A+CT{['-ON CLEAN UP CCNPLETE DATE ENFORCEMENT ACTION T / N <br />ENFORCEMENT TYPE: 1 2 3 G 5 6 DATE ACTIOR TAKEN: <br />SITE NAMEiirs <br />6PRU�PC( �s��uS <br />AOORESS <br />�fOV S, �LG7 <br />CITY <br />p STATE C4. ZIP }5 )O`/ <br />PHCNE <br />PR ICRITY .. _..------ <br />CCNTACT NAME <br />/JPn �GL C <br />PHONE <br />70 7 - 7( <br />STATE <br />ueo <br />COMPANY NAME <br />/ <br />l �� l (i/P� �fN .LGt r r S C5' <br />PHONE <br />— <br />CONTACT NAME <br />_ ��'.". <br />PHCNE <br />PR ICRITY .. _..------ <br />ADDRESS <br />CITY <br />// <br />�Gv7 /'rutiGSCJ <br />STATE <br />e n.e+r rt1 Aiff.rmr Fre Pro rCV Oiaier) <br />CCUSULTANT PHONE <br />UAR S <br />C-. ._ 1 <br />PHONE <br />�� <br />/. 1y Z.... <br />C-'MPANY NAVE <br />_ ��'.". <br />DATE C �j 2i <br />O <br />PR ICRITY .. _..------ <br />STREET It <br />PHONE <br />SITE STREET <br />C`NTACT NAME <br />ADDRESS <br />STATE <br />ZIP <br />CITY <br />CCUSULTANT PHONE <br />UAR S <br />C-. ._ 1 <br />DATE <br />�� <br />/. 1y Z.... <br />PRCP 65 d>', <br />_ ��'.". <br />DATE C �j 2i <br />O <br />PR ICRITY .. _..------ <br />STREET It <br />SITE STREET <br />jyU✓w APN Y <br />E4 :3 070 (7/89)REVTSED 03/91 89-19(IV) C.VTMFRZ <br />