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Piz PHS 4OAOUIN COUNTY - ENVIRONMENTAL HEALTH DIVI40 <br /> CONTAMINATED SITE D-Base MFR INPUT FORM <br /> UPDATE: 2 BY/J,�i,. REVIEWED BY: DATE ENTERED: / / BY: <br /> SWEEPS/SITE CODE PROGRAM/ELEMENT -o COMP # LOC CODE !ENV <br /> T # <br /> y. s <br /> LOT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGERESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT <br /> OTHER CONTACT RWOCS CONTACT WDR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 #2 1 #3 1 1 94 #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 c— <br /> ADDRESS // S 4jlv`, <br /> aA4A ��- <br /> CITY 57zr- ����1111 STATE (�1 2IP <br /> CONTACT NAME e, . K ,�� PAb�`-'I / PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE 21P <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 PROP 65 # DATE PRIORITY <br /> STREET # SITE STREET APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />