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PHS, JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DTVI <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: /3o BY: � REVIEWED BY: DATE ENTERED: / / BY: <br /> SWEEPS/SITE CODE PROGRAM/ELEMENT 9, COMP # LOC CODE Q DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PwS FILE PRIV WELL FILE !RESPtONSE' <br /> SOLID WASTE H2O O FILE EPI FILE LAND USE FILE TERYNCY <br /> LEAD AGNCY/UNIT CA�)R CA) Q C--� I <br /> SJ/EH CONTACTjj DHS CONTACT - <br /> OTHER CONTACT RWOCS CONTACT �(�l,$pv� \ WDR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT GW CONT ✓ OW CONT ETROLEUM /Y/ / N <br /> SUBSTANCE #1 ( �'7 #2 #3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y G N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME it, PL!LC <br /> ADDRESS i// frit!. OML.i.Q. >t6 C,40 (A-„ <br /> CITY Tb STATE ZIP <br /> CONTACT NAME C'f..(JW PHONE <br /> PROPERTY OWNER h <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 n PHONE <br /> UAR # DATE /PROP 65 # DATE `�zd q? PRIORITY <br /> STREET # C / SITE STREET / /� / J APPN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2`-`C� <br />