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-11 <br /> PHS/SA�AOUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: /a9 q 8X05 Y: <br /> REVIEWED BY: , L/&TE ENTERED: / / BY: <br /> SWEEPS/SITE CODE !,r�r�b PROGRAM/ELEMENT COMP # LOC CODE Q r DIST # �� <br /> n ' <br /> UGT FILE i I PILOT FILE H W FILE SITE MITIGATION PUS 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 S•�� �O. H /� SJ/EH CONTACTQn ��L{/'� DNS CONTACT <br /> OTHER CONTACT RWOCS CONTACT WOR issued Y / N NPDES issu d r / N <br /> FAILED PT SOIL CONT 'a�-q5GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 a d� � ECLEAN <br /> j"/��—� #3 1 V�_3 #4 �o� a 3 #5 <br /> PRIOR FAILED PT NO ACTION P COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS E,0 <br /> r <br /> CITY <br /> s,An C � STATE G fi ZIP q6 03 <br /> CONTACT NAME PHONE 9 r(7 l <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME � � �Q ex - PHONE <br /> ADDRESS <br /> CITY �Zy , �,��✓ l_ �2� STATE c ZIP <br /> RESPONSIBLE PARTY (if different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> [UAR # DATE —,?/— P 65 # �'S-�7 DATE �� PRIORITY <br /> STREET # .3 lJ) 9 ?SITE STREET L D4" a APN # X�[ q 6,3 <br /> ` <br /> EH 23 070 (7/89)" 89-19(IV) CNTMFR2 REVISED 12/94 <br />