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PHS/S,.,,,)AGUIN COUNTY - ENVIRONMENTAL HEALTH OIVIS! <br /> TAMINATED SITE D-Base MFR - INPUT FORM /s <br /> UPDATE: / d / BY: / REVIEWED BY: DATE ENTERED: 7 / 12- BY: <br /> SWEEPS/SITE CODE o PROGRAM/ELEMENT f OMP # LOC CODE DIST # 3 7 C <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS ' <br /> SOLID WASTE H2O G FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> (/O <br /> LEAD AGNCY/UNIT SJ/EH CONTACT �� ,�� DHS CONTACT <br /> OTHER CONTACT RWGCB CONTACT WDR issued Y ! N NPOES issued Y / N <br /> FAILED PT SOIL CONT GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 #2 #3 1 F#4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE V/ DATE ��-�3�p a— ENFORCEMENT ACTION Y / <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: ! / <br /> SITE NAME <br /> l <br /> ADDRESS <br /> CITY STATE TI2IP <br /> CONTACT NAME PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME D. / PHONE b p 3 - 7�y <br /> C)O U <br /> CONTACT NAME � PHONE �9 <br /> ADDRESS 7,?--3 <br /> CITY STATE ZIP <br /> RESPONSIBLE PARTY (If different from Property Owner) c <br /> COMPANY NAME � r PHONE p / <br /> CONTACT NAME /� PHONE <br /> ADDRESS /� J CLEC/ ftp <br /> CITY l / STATE ZIP �y 5 <br /> CONSULTANT PHONE <br /> F <br /> R # DATE PROP 65 # DATE PRIORITY <br /> STREET # �r/_ F SITE STREET 1 ,4vvJn <br /> APN # _D <br /> EH 23 070 (7/89)REVISED 003/91 89-19(IV) CNTMFR2 <br />