Laserfiche WebLink
PHS/SA!...,AOUIN CDUNTY - ENVIRONMENTAL HEALTH DIVISIO`� <br /> CONTAMINATED SITE 3-Base MFR - INPUT FORM <br /> UPDATE: / &) / / By: REVIEWED BY: DATE ENTERED: l'/J✓ /, BY: <br /> SWEEPS/SITE CODE 22/Cl PROGRAM/ELEMENT 23 COMP # LOC CODE DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE F1 LE 1 OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT - - <br /> OTHER CONTACT RWOCS CONTACT WDR issued Y / N I NPOES issued <br /> FAILED PT SOIL CONT GW CONT <br /> DW CONT ETROLEUM <br /> SUBSTANCE #1 #2 #3 #4 #5 <br /> PRIOR FAILED PT ND ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: f1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME �I ,(r i n L) _ ^ <br /> ADDRESS <br /> CITY Ciro ...� STATE 2IP QS�"7 os <br /> 11 <br /> CONTACT NAME O PHONE !/ <br /> PROPERTY OWNER <br /> COMPANY NAME n� PHONE <br /> CONTACT NAME I I +I^ C PHONE <br /> ADDRESS ' 1 l C/L)�'� <br /> CITY `l\V, `' ^ STATE /J ZIP <br /> RESPONSIBLE PARTY (If different from Property Owner) v, + <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY - STATE ZIP <br /> CONSULTANT _ PHONE <br /> UAR # DATE PROP 65 # DATE PRIORITY <br /> STREET # 7 3 SITE STREET ,,,,�y�Dq,(-d APM 9 <br /> EH 23 070 (7/89)REVISED 0/3/91 89-19(IV) CNTMFR2 v <br />