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PHS/SAN ouim COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE 0-,3as`e 4FR - INPUT FORM <br /> UPDATE: / / /�f SY: REVIEWED BY: DATE ENTERED: <br /> 1 �J BY. <br /> SWEEPS/SITE CODE PROGRAM/ELEMENT 2 9 573 1 <br /> COMP LOC CODE Q / DIST <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION f PNS F[LE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2�9,, 1� EPI FILE LAMO USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> �J <br /> LEAD AGNCYNNIT �U�wQ 0 l�'C SJ/EH CONTACT �^/�� DHS CONTACT -- <br /> t/6 */TE <br /> OTHER CONTACT RWOC3 CONTACT C n SKS WOR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CCNT 7-/Q-�Z 74 CONT 7--/0-92- OW CONT I IP <br /> ETROLEUM Y / Q <br /> SU3STANCE ,, 7�D3gZ -12 ���0 3� 7�/yo y39 � 171IV03?3 45 <br /> PRIOR FAILED PTI ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE !LAME I �Q��� <br /> 2001300 /-1NPS�jr' <br /> ADDRESS <br /> CITY <br /> STATE I �J4 ZIP <br /> CONTACT NAME I �/��- �D� S� U�LL ?NONE <br /> PRCPERTY OWNER <br /> COMPANY NAME / ; O� ���(/ PHONE !/ / <br /> CONTACT NAME ✓�� v�''r-�- PHONE <br /> ADDRESS yz5 C� <��� �i <br /> STATE ZIP <br /> CITY <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME d-e—V <br /> PHONE <br /> CONTACT NAME J < 11�C�c� PHONE <br /> ADDRESS �s A), <br /> CITY STATE ZIP <br /> CONSULTANT � PHONE <br /> UAR Y GATE P'RO_P, 65x. DATE PRIORITY <br /> STREET 9 ZOO 30b I SITE STREET L'�/ 7 APR x 137 DZ1/• d Z <br /> EH 23 070 (7/89)REVISEO 03/91 89-19(IV) C.NTMFR2 <br />