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PHS/SAN XLx;;-JIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE 0-3ase MFR INPUT FORK <br /> UPOATE: L / /R[/ Y: REVIEWED ay: MR - <br /> DATE ENTERED:/a / /`� 3Y' <br /> aWE:PS/SITE CODE R!�' PROGRAM/ELEMENT COMP # LOC CODE OIST A <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O a FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCYNNIT SJ/EH CGiTACT e.p.G� OHS CONTACT <br /> OTHER CCNTACT r• ✓ RIJOC3 CONTACT J090-6A, WOR issued Y / NPOES issued © / N <br /> FAIL'O PT I ( SOIL CCNT q �� C.1 CONT i� TOW CONT �IETROLEUM / N <br /> I�r�� MAIL 10 -111 WIR <br /> ;LssIANcE �1 -2 <br /> PR(CR FAILED PT IND ACTION CLEAN UP CCMPLETE DATE ENFCRC_MEHT ACTICH Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SI �Uxv mo <br /> ACCRESS <br /> CITY _--�'T��`�� I STATE I � ZIP <br /> CCNTACT NAME ! IPHONE <br /> <I T CWN <br /> I(cMPANY NAME PHONE <br /> CCNTACT NAMS PHON ` <br /> ADDRESS ,(](J <br /> CSTATE <br /> CITY <br /> RESPCNSTaI PARTY (If different from Property Owner) �I`v <br /> CCMPANY NAME PHONE <br /> CCNTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> PHONE <br /> =NSULIANT <br /> UAR 3 DATE PROP 65 x �I i DATE � PRIORITY '^ v <br /> STREET I 1sl 'IV SITE STREET- $ JAPH 20 af��� <br /> cH 23 070 (7i89)REVISE0 03191 89.19(Iv) CNTMFR2 <br />