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PHS/SA)�QUIN CCUNTY - ENVIRONMENTAL HEALTH OIVISIC <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / / Or BY: !"� REVIEWED BY: �7A x DATE ENTERED: / � / BY: <br /> tl�/;� WWW r; <br /> SWEEPS/SITE CODE PROGRAM/ELEMENT �j COMP # LOC CODE DIST # <br /> UGT FILE PILOT FILEH W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O D FILE EPI FILAND U <br /> LESE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CCNTACT DHS CONTACT - <br /> OTNER CONTACT RWOCB CONTACT WDR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONT GW CONT OW CONT ETROLEUM Y / N <br /> SUBSTANCE #t #2 1 #3 1 94 #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 �,�.dJ �, r/ n S /) ^�� rj <br /> ADDRESS •..,` 3""�C� li— vId ��l ,L�CITY <br /> S— <br /> CITY STATE C{/) ZIP <br /> CONTACT NAME PHONE <br /> PROPERTY OWNER IIIYYY <br /> COMPANY NAME PHONE <br /> CONTACT NAME <br /> / �I PHONE <br /> ADDRESS } toL <br /> CITY V STATE G ZIPS <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME � ��l-. D \ /� �� -.(� ✓'1 S PHONE <br /> CONTACT NAME Y ^- ^l� PHONE "7.7 3 <br /> -2- <br /> ADDRESS 1 , th � / <br /> CITY +�y STATE CN 1 ZIPS <br /> CONSULTANT PHONE <br /> UAR # DATEPROP 65 # \ DATE PRIORITY <br /> STREET # �� i SITE STREET <br /> EM 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />