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PHS/{�10UIN COUNTY - ENVIRONMENTAL HEALTH DIVI <br /> Z�NTAMINATED SITE O-Base MFR - INPUT FORM <br /> UPDATE: 6 BY:� VIEWED BY: .,Q�v DATE ENTERED: / � BY: / <br /> SWEEPS/SITE CODEll;g?-7 <br /> PROGRAM/E MENT 7,3 P COMP # Q Ac r -zl LOC CODE D # ylZ- <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PAWS FILE PR1V WELL FILE ENV ASSESS <br /> SOLID WASTE H2O O FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT - - <br /> OTHER CONTACT RWOCB CONTACT WOR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONT GW CONT �G�j DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 (LO #2 Q #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS <br /> CITY '� STATE ZIP s176 <br /> CONTACT NAMEPNONE 9.. 77 -32D61 <br /> PROPERTY OWNER <br /> COMPANY NAME Pe5+-Arm A 6PHONE <br /> CONTACT NAME sub '-7'n M PHONE Off( u—US/ <br /> ADDRESS 7 O VVVVM ^ uu <br /> CITY S" STATE C� ZIPITI �J� <br /> RESPONSIBLE PARTY (if different from Property Owner) TITI vav <br /> COMPANY NAME ' PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS "7 - Q 5-7' <br /> CITY !/ STATE IP Q <br /> CONSULTANT PHONE <br /> ^2� . <br /> UAR # �I���� DATEPROP 65 # JL 'v DATE �[/�// PRIORITY <br /> STREET ^ SITE STREET �^ APN # Z 60-0 <br /> EH 23 070 (7/ ) CNT - 2 0 r _ <br />