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PHS SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIv�ON <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: 4 / Z / BY: REVIEWED BY: DATE ENTERED: / / BY: /7 <br /> SWEEPS/SITE CODE 1 � PROGRAM/ELEMENT 'z 3,8Q COMP 0l'1IN�lJJ� LOC CODE O/ DI STS# 7 <br /> LOT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT OHS CONTACT -- <br /> OTHER CONTACT RWOCS CONTACT WDR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONT 10115/g I GW CONT DW CONT I IR <br /> ETROLEUM Y / N <br /> SUBSTANCE #1 12 O 3 Z #2 #3 1 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5f-6 DATE ACTION TAKEN: <br /> SITE NAME �5 �K) Tb u� n EIeG-t"�-tc, Tli c <br /> ADDRESS 5 3 S u�1/i o o V' <br /> CITY S'fIl/ Jl-�n STATE ZIP <br /> CONTACT NAME R 8 PHONE I Zo9- CJ(p!5- <br /> PROPERTY OWNER <br /> COMPANY NAMEC-)`- 1 ✓1 VeG�+' ?'�'S PHONE <br /> CONTACT NAME I X' ` PHONE <br /> ADDRESS <br /> CITY I VI 01/ STATE C� 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 T <br /> PHONE <br /> UAR # DATE 1 l.' �D PROP 65 # -O DATE ( j 9 gD PRIORITY <br /> STREET # 5 3 SITE STREET v�/O� -, APN # <br /> EH 23 070 (7/89)REVISED 03/91 89.19(IV) CNTMFR2 <br />