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'_EAD AGNCY/UN[ T <br />L� J G9 , <br />PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br />12 <br />SJ/EH CONTACT <br />M <br />CONTAMINATED SITE D -Rase MFR - <br />INPUT FORM <br />34 <br />_POATE: I ( <br />/-3,� /D I BY: <br />REVIEWED BY: <br />DATE ENTERED: �` /3J / (,� I <br />BY: <br />?uEEPS/SITE CODE <br />PR5 <br />PR RAM/ELEMENT .-4..ZCfi�.- <br />COMP M <br />NPDES iss..c-=: //101 <br />LOC CODE <br />DIST x <br />7G' FILE <br />Y / N <br />-A I LED PT <br />PILOT FILE <br />H W FILE <br />SIZE MIT[W"TION <br />b <br />PWS FILE <br />GW CONT <br />PRIV WELL FILE <br />Du CONT <br />ENV ASSESS <br />TOLiO WASTE <br />/ N <br />H2O D FILE <br />EPI FILE <br />LAND USE FILE <br />OTHER AGENCY REPORT <br />EMERGENCY RESPONSE <br />'_EAD AGNCY/UN[ T <br />L� J G9 , <br />u h f I J <br />12 <br />SJ/EH CONTACT <br />M <br />d3 <br />DHS CONTACT <br />34 <br />OTHER CONTACT <br />VS <br />ZIP <br />STATE cps— <br />RUDCB <br />CONTACT <br />NO ACTION <br />WOR issued <br />Y / <br />NPDES iss..c-=: //101 <br />DATE <br />CITY <br />ENFORCEMENT ACT IOlI <br />Y / N <br />-A I LED PT <br />cno r_ucur iroc• <br />1 2 <br />SOIL CONT <br />b <br />I' z_ DI <br />GW CONT <br />Du CONT <br />Ei0.0LEUNY <br />/ N <br />I SUGSTANCE <br />91 <br />get�,OILUM T,IJp, <br />12 <br />DRESS <br />5 -f - <br />d3 <br />/ <br />34 <br />ZIP <br />VS <br />ZIP <br />STATE cps— <br />P <br />:.PRIOR FAILED Pi <br />S_ONTACT NAME <br />NO ACTION <br />CLEAN <br />UP COMPLETE <br />ZIP <br />DATE <br />CITY <br />ENFORCEMENT ACT IOlI <br />Y / N <br />cno r_ucur iroc• <br />1 2 <br />3 4 S <br />b <br />DATE <br />ACTION TAKEN: <br />`EIT NAME <br />Q <br />PHONE <br />DRESS <br />5 -f - <br />CITY✓ <br />/ <br />STATE p-� <br />V„ <br />ZIP <br />Q S2 <br />ICI J�-3 <br />ZIP <br />STATE cps— <br />PHONE <br />S_ONTACT NAME <br />i <br />j COMPANY NAME <br />I <br />PHONE <br />CONTACT NAME <br />PHONE <br />/ <br />ADDRESS <br />(/C:J <br />CITY <br />ZIP <br />STATE cps— <br />An iT4 �f fFnrnnr'frr Preoerw Owmr) <br />CCMPANY NAME <br />I <br />PHONE <br />PHONE <br />CCNTACT NAME <br />ADDRESS <br />i <br />STATE <br />ZIP <br />CITY <br />:_4 S_L CANT <br />I IR y DAZE PROP » x I DATE PRIORITY <br />STREET d SITE STREET APN R <br />I <br />y '70 (7/39)- 39-19(I'/) CNTMFRZ REVISED 12/94 <br />