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E <br />SJLHD CONTAMINATED SITE MFR FORM PAGE 1 <br />NOTE: THIS FORM IS TO BE USED FOR ADDING AND CHANGING <br />INFORMATION FOR THE CONTAMINATED SITES DATA <br />BASE. ONLY THE SWEEPS NUMBER AND FACILITY NAME WILL BE <br />REQUIRED TO IDENTIFY THE APPROPRIATE RECORD FOR CHANGES. <br />ALL APPROPRIATE INFORMATION SHOULD BE FILLED OUT FOR <br />ADDITIONS TO THE DATA BASE. <br />DATE: ABSTRACTOR: c_-� KEY OPERATOR/DATE: <br />SWEEPS #: COMP#: DIST#: LOC CODE: <br />FACILITY NAME: <br />FACILITY STREET: C1 a <br />FACILITY CITY: FAC STATE: FAC ZIP: <br />FACILITY TEL: Lg"cf / e3�Z =4gZ/' FACILITY CONTACT: 6W <br />OWNER &ed4l( <br />• i0 <br />OWNER CIT�: r -o �j Y 1// Ile,J OWNER STATE: OWNER ZIP: <br />OWNER TEL: OWNER CONTACT: <br />UGST FILE: IV--�H.W. FILE: LAND FILE: WATER FILE: <br />FAILED PT: 41--�SOIL CONTAMINATION: CUBIC YDS: <br />GROUND WATER CONT: SURFACE WATER CONTAMINATION: <br />DRINKING WATER CONT: OTHER CONT: <br />TPH: BEN: TOL: XyL: ETHYL BEN: <br />EDB: SOLVENTS: AROMATICS: METALS: OTHER: <br />TANK FAILURE: PIPE FAILURE: OVERFILL: SPILL: <br />DISPOSAL: OTHER: UNKNOWN: <br />EH N 50 (1 of 2) <br />2/88 <br />