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PIIS/SAN JOADIIIN COUNTY - ENVIRONMENTAL HEALTH DIVISION' � � 1 0003�'G 7✓ <br /> CONTAMINATED SITE O-Base MFR - INPUT FORM <br /> UPDATE: D / 15 /9' BY: �(/8 REVIEWED BY: DATE ENTERED: / / BY: <br /> SWEEPS/SITE CODE Q3 11+0 a PROGRAM/ELEMENT d 3l COMP # LOC CODE DIST # <br /> UGT FILE X1 <br /> PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O G FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT -{ /� w SJ/EH CONTACT M �Ga /( DHS CONTACT <br /> OTHER CONTACT / 1 C RWOCB CONTACT WOR issued Y <br /> 1 - / N NPDES issa_s / N <br /> FAILED PT �1 In ,TSOIL CONT 8� "97 GW CONT 8 l DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 Ald� #Z #3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE /ENFORCEMENT ACTION Y / N <br /> EIIFORCEMENT TYPE: 0 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS /, /� --7 <br /> CITY /n STATE ZIP 7� 7 <br /> CONTACT NAME PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME !' Vv�JJ JJJ PHONE <br /> MAO <br /> ADDRESS /3 Z- S <br /> CITY STATE Z 21P S 73 7 <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME �/���� p .-ti .� / PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CCIISULTANNTT /-� PIIONE <br /> UAR # 7 DATE g `� PROP 65 # u./ DATE g is q� PRIORITY <br /> STREET # �� SITE/STREET �NTErsL PR ISE A P N <br /> EH 23 070 (7/89) 89-19(IV) CNTMFR2 REVISED 12/94 v, <br />