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PHS/S. OAOUIN CCUNTY - ENVIRONMENTAL HEALTH DIVIS <br /> 'nC) CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: BY: PT REVIEWED BY: DATE ENTERED: L; / - / BY: - <br /> L" 2 <br /> SWEEPS/SITE CODE I I PROGRAM/ELEMENT X3: 0 COMP I/��w 1`� I LOC CODE 0' DIST <br /> =FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> JEPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT OHS CONTACT -- <br /> OTHER CONTACT RWnCB CONTACT WOR issued Y / N NPOES issued <br /> FAILED PT SOIL CONT l d/2'�?/?o GW CONT OW CONT ETROLEUM �/ N <br /> 2 03 z3 �4 �5 <br /> SUBSTANCE "1 #2 <br /> PRIOR FAILED PT NO ACTION L CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME �(� v�ur5 <br /> ADDRESS <br /> CITY <br /> J I OC.K Y1 STATE C' ZIP ��?L 02— <br /> CONTACT NAME C� tiQi(,C) y Ll) 1(-1' PHONE <br /> PROPERTY OWNER Y <br /> COMPANY NAME �I?d�� v `K� PHONE �2 / <br /> Iq <br /> PHONE <br /> CONTACT NAME <br /> ADDRESS <br /> CITY �j. /fi� STATE c 1 ZIP <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> PHONE <br /> CONTACT NAME <br /> ADDRESS <br /> ------[ <br /> CITY STATE Z!P <br /> CONSULTANT PHONE <br /> UAR /I DATE ID�ZS/9D JPRCP 65 91 -- �� DATE i6l,40-/�,/ PRIORITY <br /> STREET $ �� SITE STREET <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />