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PHS/_' OACUIN COUNTY - ENVIRONMENTAL HEALTH DIVIS.. <br /> %CONTAMINATED SITE 0-4ase\OR PUT FORM <br /> LIPOATE: / O / Y• REVIEWED 8Y: W� �E ENTERED: / / BY: <br /> SuEE?S/SITE CODE !J PROGRAM/ELEMENT I j COMP LOC CODE I (DIST O� <br /> UGT FILE PILOT FILE I H W FILE ( SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O a FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT I OHS CONTACT — <br /> OTHER CONTACT RWOC3 CONTACT WOR issued Y / N ( NPOES issued Y / N <br /> U + <br /> IRSTROLEUMFAILED PT SOIL CCNT GW CONT OW CONT Y / N <br /> SUBSTANCE 1 ;*' �1 G� '2 1(O 6�/ 3 4 I MS <br /> PRICR FAILED PT NO ACTION CLEAN UP COMPLETE DATE1 - ENFORC-SMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME I5" bw b,+ v <br /> C <br /> ACORESS - ! 3.Y <br /> CITY STATE I ZIP I <br /> CONTACT NAMEI q0NI / , PHONE 0 <br /> PROPERTY 04NER v es <br /> COMPANY NAME pIJ T� 1 V HONE •1/f 7v <br /> CONTACT NAME �jJ� N PHONE <br /> ADDRESS I 0 /� v <br /> CITY I -�j_ ;/ STATE � ZIP <br /> RESPONSIBLE PARTY (If different from Property Owner) `/ 1 <br /> COMPANY NAME S o y V PHONE I / 3v V/ <br /> CONTACT NAME ( J� / , J � i PHONE <br /> ✓ 1 � l► `� 3•=Z <br /> ADORESS Ij f C� / , l/ 1 /��►" 1) <br /> CITY I STATE / ,_-(-ZIP <br /> CONSULTANT ( PHONE <br /> LIAR T I tl� g DATE ( / -�f//I PROP 65 T ��/!�� DATE I ` �L. �J PRIORITY <br /> STREET 9I L I SITE STREET 1 ,I <br /> D�f / APR <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNYTMFR2 6, <br /> v /' 7 ✓ <br />