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c^1 /✓WYIv CYI i <br /> r fA� COUNTY - ENVIRONMENTAL HEALTH OIVISIG� <br /> CCN,AMINATED SITE 0-8ase MFR - INPUT FORM <br /> F S <br /> UPDATE: 11 / /9 ASY: 1c 2E'/IE'JED BY: DATE ENTERED: /� / / / ( By: <br /> SWEEPS/SITE CODE PROGRAM/ECE.MENT 3 CCMP # LOC CODE DIST 9 <br /> I <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS �g <br /> .I <br /> SOLID VASTE H2O C FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> ` r <br /> LEAD AGNCY/UNIT , f SJ/EH CONTACTI� l�LGJDHS CONTACT -- <br /> OTHER CONTACT RWQC3 CCITACT WOR issued Y / N NPDES issued Y / 1 <br /> `k <br /> FAILED PT SOIL CONT 2 GW CONT OW CCNT ETROLEUMY�/ N <br /> r <br /> SUBSTANCE #1 :2. #3 <br /> f PRIOR FAILED PT NO ACTION CLEAN :F COMPLETE GATE ENFORCEMENT ACTION Y / N <br /> 1 T I <br /> I ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> 4 i <br /> k SITE NAME G f r►� V Q�c.Ll�l,SSE✓1 <br /> ADDRESS -77 ,6 Z.. 011. <br /> 4' CITY „ . �J STATE ZIP <br /> CONTACT NAME � 1� �-� �!S� PHONE I <br /> PRCPERTY OWNER <br /> M - { <br /> COMPANY NAME C+YNe—, PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> 5 <br /> RESPONSIBLE PARTY (If different from Property Caner) 7 <br /> r <br /> t <br /> i CCMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> j' ADDRESS - - - <br /> CITY w STATE ZIP <br /> CONSULTANT - PHONE <br /> X <br /> UAR = DATE PROP 65 '] DATE /V �7APN <br /> PRIORITY <br /> STREET # -[77 6 v SITE STREET .1 4. F L # 7,s7-110- 01 <br /> ,s7110- V1 <br /> EH 23 070 (7189)REVISED 03/91 89-19(IV) C.4TMF?2 " <br />