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PHS/SAIypAA0U1N COUNTY - ENVIRONMENTAL HEALTH DIV_IS16y <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / / 1 BY � REVIEWED BY: DATE ENTERED: �'rj //_S /f'--� BY: 1 <br /> SWEEPS/SITE CODE vTr <br /> PROGRAM/ELEMENT Z� O t) I <br /> COMP co/6 LOC CODE <br /> UGT FILE >C PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS 1 <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNTT SJ/EH CONTACT DHS CONTACT <br /> OTHER CONTACT RWOCB CONTACT WDR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT Y ����J" GW CONT OW CONT ETROLEUM / N <br /> Y <br /> SUBSTANCE #1 /L�'?�2, #2 / 7:G 3 93 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 T ` ✓�� /^G/ '/jA� <br /> ADDRESS •L./ 6 I S / [� V / // S <br /> CITY 72A-(/ STATE ZIP -7 <br /> CONTACT NAME M kLOs PHONE ✓ /�17���/�Qd <br /> PROPERTY OWNER <br /> COMPANY NAME AN 71 DC/Oc O a 72f PHONE S/0,—7 f.�JC� <br /> CONTACT NAME -1]- _� LS ��i� PHONE S^-�l rQ� 7 <br /> ADDRESS j O - -!�oMGRs v&-L <br /> CITY /- f V 1 1 STATE �._- 2IP 7 6 <br /> RESPONSIBLE PARTY (If differen[ from Property Owner) <br /> COMPANY NAME 4-MF, <br /> PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY - STATE ZIP <br /> CONSULTANT PHCNE <br /> UAR # �2�)A �� DATEZif, PROP 65 # 93_psi, DATE <br /> ( L.� �� PRIORITY <br /> STREET # SITE STREET ��� (I.r ST I APN # <br /> EN 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 v� <br />