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_ -- • • CAT 000(o '_� 4/ (p 3 � <br /> POTENTIAL HAZARDOUS WASTE SITE <br /> REGION I E NUMBER(te e..� <br /> 085 .,arlW b,H� <br /> IDENTIFICATION AND PRELIMINARY ASSESSMENT <br /> NOTE: This form is Completed fpr each potential hazardous taste site to help art priorities for site insPeetiom The information <br /> submitted on this form is based on available records and may be updated on subsequent forma as • result of additional inquiries <br /> and onsite inspectlons. <br /> GENERAL INSTRUCTION& Complats Sections I and M throw S as completely as possible before Se@oa H(Prolimitlary <br /> AseeasmoW,a <br /> I. SITE IDENTIFICATION <br /> A. 317! Mt-da B. STREETI(ot that IC.nrlflr) <br /> -Ikt(a)q - `PO <br /> C. CITY D. STATE E. ZIP CODE F. COUNTY NAME <br /> M1' Pr -r- CA 4s3310 �Iv Jon <br /> G. OWMER/OPLRATOR(it Jew.) <br /> I. NAM[ x. T[LEPHON[ NUMa[R <br /> PfMb-TAR (20R-Ru q-TioN x1� <br /> M. TYPE Of OWNERSHIP <br /> [Z1. FEDERAL [:]2. STATE C3. COUNTY C-]A. MUNICIPAL E20. PRIVATE E16 UNKNOWN <br /> I. SITE DESCRIPTION <br /> J. HO.W�IDENTIFIED(Id., clfn.n'. coepbinv. OSHA cinnen.. .,C.) K. DATE IDENTIFIED <br /> W A.`3tf.. �lS'} OSR�- Lj�E 3K 2V E� (mo., day,as- 17 <br /> 6 11 <br /> L. PRINCIPAL STATE CONTACT <br /> 1. NAM[ 2, TELEPHONE NUMDER <br /> �up1Tl1 1I(�fgLe DePT OF l46ALTN S\JC-S deco) 3�3-�o4a <br /> II. PRELIMINARY ASSESSMENT (complete this section fest) <br /> A. APPARENT SERIOUSNESS OF PROBLEM I-7-� �/ <br /> 1`71. HIGH Q2. MEDIUM 0F <br /> 3. LOW 4 NONE XIS. UNKNOWN <br /> e. RECOMMENDATION T` <br /> 1. 140 ACTION NEEDED(no heard) ❑2. IMMEDIATE SITE INSPECTION NEEDED <br /> •. TENTAT'VELY SCHEDULED FOR: <br /> 3•SITE INSPECTION NEIDED <br /> a. T[NTATIVaL\ ICH[DUL[D FOR: b. WILL SE PERFORMED by: <br /> b. WILL a[ P[RroRMaD my: <br /> IXl a. SITE INSPECTION NEEDED(i.P Prtority) <br /> C. PREPARER INFORMATION <br /> 1. NAY[ x. TELEPHONE NUMSER 3. OA tE(mo.. day. a Vt-) <br /> t4F LE Icy) I 1t10i-61SI <br /> III. SITE INFORMATION <br /> A. LITE STATUS <br /> 1.IACTIVE(TTeaa lMraivial 42. INACTIVE(TMu F OTMfR ("P..'")' <br /> mr.100.1.Bu WA,ch r.Win, Ua.d . lar PAIcA t10 lenpr r.ca l.. oar art.. that mclud. .nch ItIld.nt. Ilk. "m1 t/ht dlmipin/" .hr. <br /> for weal."am.,, stomal.. r dfapooe) Penna.) na n/VL.or ...f,nWln/ vu Pt III. .tn for Paan di.P...I has occ.,.d.) <br /> on•cand'"I basis, vow If'Mma- <br /> el—d'). <br /> B. IS GENERATOR ON SITE? ��..yy <br /> 01. No IXI s YES(aMe,ry 9...nr'. rev-d,/lt SIC Cod.): <br /> C. AREA OF SITE(N ane.) 0. IF APPARENT SERIOUSNESS OF SITE 13 NIGH, SPECIFY COORDINATES <br /> 1. LATITUO[(dq,­Iarw.-a.c.) x. LONGrt WOE <br /> ln.Vlk•.✓`lye r\1 <br /> E. ARE THERE BUILDINGS ON THE SITS? <br /> CD 1. Ro 0 i YES(aPealfF): <br /> EH 215A(3180) Conon Wr• On Re vrr.. <br />