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P� XACUIN COUNTY - ENVIRONMENTAL HEALTH DIVIS �J/{J JUN 14 19� <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM /l/"•,/"W <br /> 17 <br /> UPDATE: 8 / /q'1("BJy: pv REVIEWED Y� DATE ENTERED: l By: / <br /> SWEEPS/SITE COO lq LA� PROGRAM/e E14E4T J CCMP # K U(� LOC CODE b f OI # 3 Z <br /> UGT FILE PILOT FILE 1 H W FILE ( SITE MITIGATION v PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOL10 WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT 'I//-�S c#-b SJ/EH CONTACT \ .ihS�d DHS CONTACT -- } <br /> OTHER CONTACT 7 f` RWC3 CCNTACT WOR issued Y / N NPOES issued Y <br /> ls <br /> i <br /> FAILED PT SOIL CONT ( j y/- GW CONT DW CONT ETROLEUM N <br /> Y ! <br /> SUBSTANCE #1 X203 #2 ( #3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME 81 Khoro Ccu b <br /> ADDRESS ('l O 11C-I'l�Y/� -Drive-- <br /> CITY l/ STATE /� ZIP 6Z 0'-/ <br /> _ <br /> v <br /> CONTACT NAME /J L S PHONE 5��7 <br /> gc <br /> PROPERTY OWNER C/ v , <br /> COMPANY NAME CC�/1/1/1 Q PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> t <br /> CITY STATE ZIP <br /> RESPONSIBLE PARTY (If different from Property Owner) ,r <br /> COMPANY NAME �/i nnn /1 PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS 4 <br /> I <br /> CITY STATE ZIP <br /> CONSULTANT PHONE , <br /> UAR # _\\ ATE g/ /q' PROP 65 # �1 1 DATE8 2 q/ PRIORITY ' <br /> STREET # O� <br /> SITE <br /> STREET �I K hbr n AP" # <br /> I <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) C.NTMFR2 <br />