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PHS/ OACUIN CWNTY - ENVIRONMENTAL HEALTH OIVIS.� J <br />CONTAMINATED SITE D -Base MFR - INPUT FORMI . 14f111Y� i <br />UPDATE: /Z�� /9� BYE ®� /IEVIEWED BY: <br />/ BY: <br />SWEEPS/SITE <br />O y <br />U <br />PROGRAM/EL MENT <br />2 "?J <br />CCMP # <br />t �Jd <br />i <br />LOC CODE <br />Q3 <br />DIST 4 <br />R',AC3 CCNTACT <br />UGT FILE <br />\CODE <br />X <br />/ <br />PILOT FILE <br />Y <br />H W FILE <br />NPOES <br />SITE MITIGATION <br />Y / N <br />PWS FILE <br />#5 <br />PRIV WELL FILE <br />RIOR FAILED PT <br />ENV ASSESS <br />NO ACTION <br />SOLID WASTE <br />CLEAN UP COMPLETE <br />H2O O FILE <br />EPI FILE <br />LAND USE FILE <br />/ N <br />OTHER AGENCY REPORT <br />ERGENCY RESPONSE <br />I <br />LEAD AGNCY/UNIT <br />SJ/EH CONTACT <br />SOIL CONT <br />DHS <br />NTACT <br />t �Jd <br />i <br />- <br />OTHER CONTACT <br />R',AC3 CCNTACT <br />SUBSTANCE <br />#1 <br />WOR issu <br />Y <br />/ N <br />NPOES <br />issued <br />Y / N <br />II <br />FAILED PT <br />it <br />SOIL CONT <br />'12A i1 <br />7 <br />GW CONT <br />t �Jd <br />i <br />DW CONT <br />ETROLEUM <br />Y / N <br />SUBSTANCE <br />#1 <br />/ 2 / <br />92 <br />ZIP <br />#3 <br />APN # <br />74 <br />#5 <br />RIOR FAILED PT <br />NO ACTION <br />CLEAN UP COMPLETE <br />DATE <br />ENFORCEMENT ACTIONY <br />/ N <br />ENFORCEMENT TYPE: 1 2 3 "r- 5 6 DAT)�ACTION TAKEN: —/—/ <br />SITE NAME <br />U <br />ADDRESS <br />1 ��✓/_` <br />'5-- /M / <br />Gam/ <br />// <br />CITY <br />STATE <br />ZIP <br />7-1 0 I B O 6DD <br />CONTACT NAME <br />vLj ,e�M �,� <br />PHONE <br />PROPERTY OWNER / <br />COMPANY NAME <br />eT G <br />PHONE <br />V <br />CONTACT NAME <br />PHONE <br />ADDRESS <br />7-1 0 I B O 6DD <br />CITY <br />' <br />STATE. <br />2IP <br />ZIP <br />RESPONSIBLE PARTY (If different from Proper t/OWne4 <br />COMPANY NAME <br />.A I e, v EiZ4 <br />s <br />PHONE <br />CONTACT NAME <br />I/M"V Cn <br />V l� <br />PHONE <br />ADDRESS <br />7-1 0 I B O 6DD <br />CITY <br />STATE C <br />2IP <br />i <br />CONSULTANT PHONE <br />WR # <br />yt�iV7> <br />GA/TE/��/9,(/ <br />PROP 65 # <br />9/ Qr6/ <br />DATE <br />(0 /.�9/yy <br />PRIORITY <br />STREET # <br />�/-1 h <br />SITE STREET <br />i <br />&AAA✓T <br />APN # <br />;7111ya0—/7 <br />EN 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />