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PIIS/SAII <br /> pAQUIN CCUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE O - Base MFR - INPUT FORM <br /> BY : <br /> REVIEWED BY : DATE ENTERED : <br /> 0Y : , I DIST # <br /> LOC CODE <br /> COMP # <br /> /SITE LODE PROGRRM/ELEMENT ENV ASSESS <br /> � / H W FILE SIZE MITIGATION <br /> PUS FILE PRIV WELL FILE <br /> LE K PILOT FILE EMERGENCY RESPONSE <br /> H2O O FILE EPI FILE <br /> LANG USE FILE OTHER AGENCY REPORT <br /> WASTE <br /> DHS CONTACT <br />� SJ/EH CONTACT 1GNCY/UNIT IJOR issued Y N NPDES issue ' / N <br /> / <br /> ' Rtx1Ge CONTACT <br /> CONTACT <br /> DU CONT ETROLEUM Q / N <br /> 0 PT SOIL CONT (o /f8 GW CONT <br /> # <br /> #4 #5 <br /> 2 #3 <br /> fANCE 91 a. Qsoltntc ENFORCEMENT ACTION Y / N <br /> R FAILED PT NO ACTION <br /> ✓ CLEAN UP COMPLETE GATE <br /> ENFORCEMENT TYPE : 1 2 3 4 . 5 6 DATE ACTION TAKEN : <br /> : NAME <br /> z>-tar �cymGs LLG <br /> 0 ( OLO <br /> )DRESS ` .moi S t � � r� ^ M ZIP `fU U�"') <br /> STATE Lifd <br /> CITY �(Y.11' -1G�' PHONE <br /> ITACT NAMEC�\ <br /> )ERTY OWNER IPHONE <br /> MPANY NAME ` 'f- 1 S"f Q.,`(' �VOYYIGS LLL' _ <br /> PHONE <br /> INTACT NAME <br /> C),5 (p Q <br /> ADDRESS �� ©AZIP <br /> STATE C.� " <br /> CITY � a�, <br /> SPONSIBLE PARTY ( If different from Property Owner ) PHONE <br /> :OMPANY NAME PHONE <br /> CONTACT NAME <br /> ADDRESS ZIP <br /> STATE <br /> CITY <br /> PHONE C2�1) 639 - 2895 <br /> CONSULTANT <br /> LIAR # q(, uDATE 102d/Q'f PROP 65 # <br /> DATE � /2O PRIORITY <br /> 1 how it <br /> STREET # 1 3 2.S SITE STREET Corr re \ k, 0 <br /> gq- ig( IV ) CNTMFRZ REVISED 12 / 94 <br /> i7iA01- <br />