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PIIS*N JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE/Dy-Base MFR - INPUT FORM (�93ry <br /> UPDATE:�b / II n/q3 BY:S. h S&t)REVIEWED BY: �'� 1, DATE ENTERED: OCT 1 Q v 19B <br /> SWEEPS/SITE CODE / 3�1 PROGRAM/ELEMENT `1'3'Q COMP # LOC CODE DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MVITIGATION 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 J/EH CONTACT b"V`- DHS CONTACT <br /> S , <br /> OTHER CONTACT RWVCB CONTACT WDR issued Y //N) NPDES issued Y <br /> FAILED PT SOIL CONT (Q �� 1a3 GW CONT DW CONT l./ ETROLEUM 0/lNN <br /> SUBSTANCE #1 #2 #3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y ! N <br /> EIIFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS /JL -7 �pnirC: J <br /> CITY ! / �G./ STATE �1/.✓1 ZIP Sin <br /> CONTACT NAME PHONE dU <br /> PROPERTY OWNER / <br /> COMPANY IIAME L PHONE <br /> CONTACT NAME L ( (((L PHONE <br /> ADDRESS 1301 W. leoimkjoe 1 <br /> CITY 0O . !/ STATE C� ZIP QC`1w <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 # 2-1/� DATE O �� (�� PROP 65 # �'—/ DATE O /2 PRIORITY <br /> STREET #v ILv�GGG� I SITE STREET APN # /�S� n7]_ O 1 <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 ! (/ v, j'/ <br />