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PHS/SAN JO)OSUIN COUNTY • ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE D-8 a MFR INPUT FORM p <br /> UPDATE: /a /pl f / BY: �� REVIEWED BY: DATE ENTERED: / / /.5/ BY: Soo <br /> SWEEPS/SITE CODE 50J T b'�j PROGRAM/ELEMENT �J7cn COMP # LOG CODE I DIST # - <br /> UGT FILE PILOT FILE (v H W FILE SITE MITIGATION PWS FILE PRIV WELL FIL1E ENV ASSESS <br /> SOLID WASTE n820 0 FILE EPf FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT /- SJ/EH CONTACT DHS CONTACT <br /> OTHER CONTACT RWOCB CON T�A1CT WOR issued Y / N NPDES issued t / N <br /> FAILED PT ��I UUU SOIL CONT /a-p I' q� GW CONT ?0W=ETROLEUMN <br /> SU8STANCE #1 la o3 #2 71 `f 3 a-- #3 )0&PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE Cj/ N <br /> EIIFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: a LG <br /> SITE NAME <br /> ADDRESS (�S������ 1 <br /> CITY 7-i� meq^ STATE C ZIP ry <br /> CONTACT NAME nn . 1GC/GT �V�� 4� �G PHONE q)5, <br /> PROPERTY OWNER lYl v1n .n <br /> COMPANY NAME f n /yl GV•( (� �/ I PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS ��C� c� <br /> CITY (✓ /� r� STATE <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME _ PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> PHONE <br /> CONSULTANT /j <br /> UAR # yy-u 70 DATE /a-a/-�.(/ PROP 6/5��I#�1 �//�(i47 DATE `a-� �' PRIORITY <br /> STREET # l &S& S SITE STREET / Cv-4 )NE APN # <br /> EH 23 070 (7/89)' 89-19(IV) CNTMFR2 REVISED 12/94 <br />