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PH /3A1 COUNTY - ENVIRONMENTAL HEALTH DIVlrt6N <br /> TAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDAT : / /! y BY: REVIEWED BY: DATE ENTERED: JUL U& 1994 BY: <br /> SWE XSITE PROGRAM/ELEMENT �gCCMP # LOC CODE DI # <br /> FILE PILOT FILE H W FILE SITE MITIGATION PUS FILE PRIV WELL FILE TENVASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE :LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT I/ S SJ/EH CONTACT (?,�/(�) DHS CONTACT <br /> OTHER\CQNTACT '( RWOCB CONTACT WDR issued Y / N NPDES issued FY / N <br /> FAILED PT SOIL CONT GW CONT DW CONT 1PETROLEUM Y <br /> SUBSTANCE #11 ;71VD ("b(� #2 #3 7(/31�zi #4 7 /aV737 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETEDATE ENFORCEMENT ACTION Y / (0 <br /> EIIFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS <br /> CITY STATE C ZIP <br /> CONTACT NAMEg�,� / PHONE 9V4—,S <br /> PROPERTY OWNER '/ (J <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <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 /> ___J <br /> UAR # DATE PROP 65 # DATE PRIORITY <br /> STREET # SITE STREET FAP # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />