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PHS/SAN JO,%W COUNTY - ENVIROPIME14TAL HEALTH DIVISION <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: BY:QI•,El'(C� REVIEWED BY: DATE ENTERED: 5 / / l / /� BY: ✓) <br /> SWEEPS/SITE CODE 7 PROGRAM/ELEMENT CCMP # LOC CODE 4 DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FI LTE ENV ASSESS <br /> SOLID WASTE H2O O FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENr,Y RE SPnNSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT /FI/IQ/2 DHS CONTACT — <br /> OTHER CONTACT RWOCB CONTACT WOR issued Y / N NPDES issu--- / N <br /> ;,AILED PT SOIL CONT - -- GW CONT OW CONT ETROLEUM Y / N <br /> TANCE 43 #4 #5 <br /> 3 #2 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION LCY / N <br /> ENFORCEMENT TYPE: 1 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS <br /> _ STATE ZIP <br /> CITY y� ,��/V� <br /> CONTACT NAI4E A/wvS n PHONE C��� �a _ �� ' <br /> PROPERTY OWNER "G✓ Kf <br /> PHONE <br /> COMPANY NAME ) <br /> S L W PHONE �,q,9 <br /> CONTACT NAME r� W <br /> ADDRESS P 1--C�1ITX ./ <br /> CITY ��c�/„� /'�f o STATE C4 21P j/ 6,35 / <br /> RESPONSIBLE PARTY (if different from Property Owner) <br /> / f <br /> PHONE <br /> COMPANY NAME <br /> PHONE <br /> CONTACT NAME <br /> ADDRESS <br /> STATE ZIP <br /> CITY <br /> PHONE <br /> CONSULTANT <br /> [STREET <br /> II DATE 5-13 / 6 PROP 65 # �O 5 DATE S—/3- ?9' PRIORITY SITE STREET ✓ APN # , �EH 23 070 (7/89) `J 89-19(IV) CNTMFR2 REVISED 12/94 <br />