Laserfiche WebLink
PHS/� "OACUlN COUNTY - ENVIRONMENTAL HEALTH DIYISI <br /> 0}ITAMINATED SITE 0-Base MFR - INPUT FORM <br /> Y:' DATE ENTERED- I I �1 By: <br /> UPDATE: �' / �! /g Z 9Y:- /�!/ REVIEWED BY: <br /> SUEE?S/SITE CODE PROGRAM/ELEMENT <br /> COMP # LOC CODE Q DIST # 3�� <br /> f <br /> UGT FILE LOP H W FILE SITE MITIGATION PWS FILE PRlV WELL FILE ENV ASSESS <br /> AGENCY REPORT EMERGENCY <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER RESPONSE <br /> i� <br /> LEAD AGNCY/UNIT <br /> S,!/EH CONTACT N�u � DHS CONTACT <br /> E <br /> OTHER CONTACT RWOCB CONTACT UDR issued Y / N NPDES issued Y ! H <br /> i <br /> li <br /> FAILED PT / / SOIL CONT / / GW CONT / / DW CONT PETROLEUM Y / N <br /> SUBSTANCE #1 #2 #3 #4 95 <br /> q ••I <br />#. PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE 3 /�� /!Z ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> �i <br /> SITE NAME <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONTACT NAME �., �4 /yd�� PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME Gt.- PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS 5 C <br /> CITY STATE TZ <br /> 7p ; <br /> I <br /> RESPONSIBLE PARTY (If different from Property Owner) I <br /> COMPANY NAME PHONE �I <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> � t <br /> CITY STATE ZIP <br /> it <br /> CONSULTANT / PHONE iI <br /> G a <br /> UAR # DATE PROP 65 # DATEI PRIORITY <br /> STREET # (� SITE STREET L Q(�� 5 APH #�C <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br /> Y - <br />