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PHS/S, AOUIN COUNTY - ENVIRONMENTAL HEALTH D1VIS1 <br /> -,dTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: I / 9(] IqZ, BY: REVIEWED BY: DATE ENTERED://erl BY. <br /> SWEEPS/SITE CODE C�J PROGRAM/ELEMENT 2-12 h COMP # LOC COO` E DIST # <br /> UGT FILE LO//PI/FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS x <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT � DHS CONTACT <br /> OTHER CONTACT RWOCB CONTACT WDR issued Y / ON NPOES issued Y / <br /> FAILED PT / / SOIL CONT / / GW CONT / / DW CONT PETROLEUM 0 / N <br /> SUBSTANCE #1 #2 #3 #4 #5 <br /> PRICR FAILED PT NO ACTION CLEAN UP CCMPLETE DATE / / ENFORCEMENT ACTION Y / N <br /> ENFCRCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME _ m— /I,, /, "d <br /> n <br /> ADDRESS 96�- <br /> CITY S/vCkkK STATE Ln` 2IP <br /> CONTACT NAME 1 V 1 PHONE C�l�/_2 G✓/ <br /> PROPERTY OIWNER a E17 <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 PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> UAR # DATE PROP 65 # DATE PRIORITY <br /> STREET # 90 SITE STREET S ///,f/,„�✓ APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 / vv 1�6� <br />