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PHS*J0A0UIN COUNTY - ENVIRONMENTAL HEALTH DIVISO <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM 4111 <br /> UPDATE: /ys/ 9/ BY: / REVIEWED BY: DATE ENTERED: BY: <br /> SWEEPS # ITE CODE COMP # LOC CODE DIST <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION v PWS FILE PRIV WELL F/ILE/ ENV ASSESS <br /> SOLID WASTE H2O O FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT H W SPILL/DISPOSAL <br /> PROGRAM/ELEMENT �6 / LEAD AGENCY/UNIT a CIQ �L SJ/EH CONTACT <br /> RWOCB CONTACT �S, �c`/" DHS CONTACT OTHER CONTACT <br /> FAILED PT SOIL CONT GW CONT DW CONT PETROLEUM Y / N <br /> SUBSTANCE #1 #2 1 #3 1 1 #4 1 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME PHONE <br /> ADDRESS <br /> CITY G STATE / ZIP <br /> CONTACT NAME CJ PHONE <br /> PROPERTY OWNER <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 Qr, e � PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS h <br /> dt <br /> CITY (CJl L/ STATE ZIP <br /> c—k 16 <br /> CONSULTANT PHONE <br /> i <br /> PAR DATE PROP 65 # DATE# SITE STREET APN # <br /> EH 23 070 (7/89)REVISED 01/91 89-19(IV) CNTMFR2 , <br />