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PIIS/S. J�.N CCUNTY - ENVIRONMENTAL HEALTH DIVISI <br /> CONTAMINATED SITE D-Base MFR - INPUT FCRM <br /> JPOAiE. 9YRE'lIEWED 9Y• GATE ENTERED: l / � /�� BY: <br /> / / : • <br /> �1 PROGRAM/ELEMENT LOC CODE DIST x <br /> S!.'EE:?S/SITE CODE _ V— <br /> UGI .:!LE PILOT FILE H u FILE SITE MITIGATION PWS FILE PR III WELL FILE ENV aSSESs <br /> SOL:-) WASTE H2O 0 FtLE EPI FILE LAND USE Ft LE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> __T <br /> FAD AGNCY/UJ• G+ <br /> ACT OHS CONTACT <br /> NIT" SJ/EH CCNT <br /> .FHE2 CONTACT. <br /> RIAC3 CONTACT WOR issued Y / N NPOES issued Y / N <br /> CCNT 22 GW CONT OW CONT ETROLEUM Y / N <br /> Nail°0 PT SOIL (/�7 <br /> 43 14 ;*55.41STANCE #1 U ?� #2 <br /> NFORCEMENT ACTION <br /> QICR FAILED PT NO ACTION CLAN UP COMPLETE DATE <br /> EY / N <br /> 7. <br /> EIIFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> ^:ITE EAMEF�/,A, DG v �/ <br /> t STATE �� ZIP �t) �7p <br /> . _.. <br /> CITY /f/J'7i�1"'r�t�i <br /> ;;ONTACT NAME <br /> /.��� /(��`-�5 PHONE <br /> '-gCP_RTY OWNER <br /> PHONE 2•C�, S' _ 72�c� <br /> �CMP.4NY NAME TG� V� -�• Lam• <br /> L _ PHONE (Z,�J �zj- 3�G v <br /> �,t1N i ACT NAME � �� •� �� <br /> ADDRESS p., d 7jZ <br /> STATE Z[P <br /> C:TYij <br /> RESPONSIBLE PARTY (if different from Property Owner) <br /> PHONE <br /> :MPANY NAME <br /> PHONE <br /> CCNiACT NAME <br /> AOCRESS <br /> STATE ZIP <br /> L <br /> TY <br /> PHONE <br /> CC+ISULTANT g1l <br /> LIAR 3 l�—u� GATE 1PROP. b # a�—O�S DATE` 111 STR£ET• # �E7� SI ��GrjGG[� APN w <br /> 070 c�/s9) a9-.t4(i'/) CNTMFR2 REVISED 12/94 <br />