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PIIS/SAN J IN COUNTY ENVIRONMENTAL HEALTH DIVISI ON0 <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / / BY: REVIEWED BY: DATE ENTERED: I / / BY: /r C <br /> SWEEPS/SITE CODE 1 G� ' PROGRAM/ELEMENT COMP # LOC CODE DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT J/EH CONTACT CONTACT <br /> OTHER CONTACT RWQCS CONTACT WDR pissued Y / N NPDES iss, - / N <br /> FAILED PT SOIL CONT 3I X61 •L> GW CONT 3 ((,L G1 yeti DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 #2 Y3 v v#4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE EIIFORCEMENT ACTIOtI Y / N <br /> ^ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS 1T2 rj� I <br /> CITY �I\AUy�.G STATE rJ� ZIP q <br /> CONTACT NAME 1• \` G� PHONE no �.J c-J'7 2^ IC <br /> PROPERTY OWNER ` J <br /> COMPANY NAMEPHONE r/ C <br /> PHONE 11 !/, <br /> CONTACT NAME <br /> ADDRESS <br /> CITY <br /> RESPONSIBLE PARTY (if different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> PHONE <br /> CONSULTANT/�!� <br /> EUAR # �I'A— U Ogg, <br /> /1 <br /> 1PROPE61' # � DATE PRIORITY <br /> 1 f/ V "1 ET # 2 Sr STREET �yEH 23 070 (7/89)' l 89-19(IV) CNTMFR2 REVISED 12/94 <br />