Laserfiche WebLink
PHS/SAN WIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE 0-3ase MFR - INPUT FORM <br /> BY: REVIEWED <br /> r ; , y 199�) By. <br /> UPDATE: l(r7 <br /> // �J REVIEWED BY:' /�' DATE ENTERED: �- <br /> � / /L� <br /> ©3 PROGRAM/ELEMENT <br /> LOC COOE Q/ DIST $ 3�� <br /> SWEEPS/SITE COOS <br /> UGT FILE /V' PILOT FILE H W FILE SITE MITIGATION <br /> PUS FILE PRIV WELL FILE ENV ASSESS <br /> SOl[0 WASTE H2O '''I <br /> FILE EPI FILE <br /> LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> �y SJ/EH CONTACT / V"� DHS CONTACT -- <br /> LEAD AGNCY/UNIT �(��Cfj- �6 <br /> /1 , <br /> ��JQrjT� '.JOR issued Y / Q NPOES issued Y / <br /> OTHER CONTACT RWOC3 CONTACT 4 <br /> /1t- <br /> GW CONT ��-8 "d 9 OW CONT ETROLEUM Y / <br /> FAILED PT SOIL CONT ��z� . S9 <br /> c 93 xs <br /> SUBSTANCE 41 92 <br /> PRIOR FAILED ?T NO ACTION CLEAN UP COMPLETE <br /> Y DATE 7-`P-p3 ENFORCEMENT ACTION Y / <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME I <br /> I <br /> AOCRESS IC'' <br /> STATE � ZIP <br /> CITY <br /> I ?HONE <br /> CONTACT `TAME <br /> PRCPERTY OWNER <br /> 4 ,�L PHONE <br /> COMPANY NAME /O•Gs�•t <br /> - PHONE ��3 • ��l S <br /> CONTACT NAME f� <br /> ADDRESS �� � � �• �a-["'�- <br /> STATE � ZIP �J Lll <br /> CITY <br /> RESPONSIBLE PARTY (If different from PropertY Owmer) <br /> PHONE <br /> COMPANY NAME <br /> PHONE <br /> CONTACT NAME <br /> ADDRESS <br /> STATE ZIP <br /> CITY <br /> UAR I <br /> DATE PROP 65 S�/-2?j / DATE ��-�D'a PRIORITY <br /> STREET � SITE STREET �.�5 l� C <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) C.VTMFR2 <br />