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PNS/SAN SQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / / BY: REVIEWED BY: DATE ENTERED: / ! /27',� BY: ` � <br /> SWEEPS/SITE CODE , PROGRAM/ELEMENT 262,b CCMP it LOC CODE DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRI WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EFI FILE CAVO USE fILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT ^" � DHS CONTACT <br /> OTHER CONTACT RWQCB CONTACT _ WOR issued Y / N NPDES iss": / N <br /> FAILED PT SOIL CONT GW CONT OW COIIT �ETROLEUM Y / N <br /> SUBSTANCE 01 120 3 Z #2 03 94 #5 <br /> PRIOR FAILED PT NO ACTION CLEAR UP COMPLETE DATE ENFORCEMENT ACTION <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESSma \ ll <br /> CITY STATE `p ZIP 0 06 <br /> CONTACT MAME PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME 1 PHONE <br /> CONTACT MA14E �• PHONE r 7 f�S <br /> ADDRESS Q1 -7 <br /> CITY STATE (34► ZIP <br /> .s <br /> RESPONSIBLE PARTY (if different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT MANE PHONE <br /> ADDRESS <br /> r <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> AA <br /> UAR # 1� GATE !_ ' PRS 65 # DATE IZ PRIORITY <br /> uuu ( <br /> STREET # -1 SITE STREET APN # <br /> EN 23 070 (7/89Y 89-19(IV) CNTMFR2 REVISED 12/94 <br />