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PHS/SAN *F%WN COUNTY - ENVIRONMENTAL HEALTH DIVISION Y� <br /> CONTAMINATED SITE O-Base MFR - INPUT FORM <br /> NFILEPILOT <br /> / BY:/ REVIEWED BY: DATE ENTERED: / ?i/ BY: <br /> rj�'Z, PROGRAM/E MENT 0 oCCMP 0 /� yG� LOC CODEDIST FILE H W FILE ' SITE MITIGATION PWS FILEPR1V WELL FILE ENV ASSESS <br /> H2O O FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEADAGNCY/UNIT cl� SJ/EH CONTACT OHS CONTACT <br /> OTHER CONTACT lS RNDCB CONTACT WDR issued Y / N 11 NPOES issued Y / N <br /> FAILED PT SOIL CONT � .�,"1 ,_ / GW CONT DW CONT ETROLEUM �/ N <br /> SUBSTANCE #1 1 J n 17 // _ #2 / #3 94 #5 <br /> PRIOR FAILED PT [ NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT .ACT ION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> T ! <br /> SITE NAME G - <br /> ADDRESS / /� r 1 I I S- <br /> LITYI L STATE <br /> P-6 C�- ZIP <br /> CONTACT NAME /"-' y �- 1 � ! PHONE <br /> 10 <br /> PROPERTY OWNER 'V <br /> COMPANY NAME Q- , 6s (-}-/�� � V / L� 5 �-f0 PHONE 70743-1 <br /> , 1 <br /> CONTACT NAME '���///)��� C v "'M1- d4- 1 'J*V� PHONE <br /> ADDRESS y� <br /> CITY 1 �1� G STATE C ZIP <br /> RESPONSIBLE PARTY (if different from(Property Owner) ✓ <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT �7PHONE <br /> UAR # a `� ', l DATE 7-i ry _ PROP 65 # �� t DATE �I — I�l fi 1 PRIORITY <br /> STREET TE STREET C, g� � r� `G I IAP_NI#/ <br /> EH 23 070 (7/89)REVISED 03h, 89-19(IV) CNTMFR2 �j(J iV 1 <br />