Laserfiche WebLink
PHS/ OAOUIN COUNTY - ENVIRONMENTAL HEALTH DIVI <br /> OW � <br /> NTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATET — By: Lr REVIEWED BY: " DATE ENTERED: /�' / / CBY: <br /> SWEEPS/SITE CODEE/Cv/a PROGRAM/ELEMENT �3.� CCMP Al LOC CODE DIST <br /> UGT FILE PILOT FILEH W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> F. <br /> SOLID WASTE H2O O FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT - - <br /> OTHER CONTACT PRW40CSTACT Gp WOR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONT !I�Z� _Q� GW CONT DW CONT I IPETRCLEUM Yf / N <br /> SUBSTANCE 91 / b 3 X2 !! k3 94 XS c� <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE GATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 S 6 DATE ACTION TAKEN: <br /> SITE NAME .� S �1✓ �� <br /> ADDRESS —7 <br /> CITY � �j 1� ' l STATE C2IP �5 Q0--2, <br /> CONTACT NAME liter v PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME PHON (� r <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY Loc, <br /> \ STATE ZIP <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY - STATE 2IP <br /> CONSULTANT _ PHONE <br /> UAR x ,., /� I DATE /�� ' PROP 65 9 - , DATE 70�-4/ PRIORITY <br /> STREET X V SITE STREET ,/1 q1V� APR 9 IC 1_'2 <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 vI u, \ 17 <br />