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PHS/ JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVIS"me <br /> ~CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / / BY•:i EVIEWED BY: DATE ENTERED: �'z BY: r <br /> SWEEPS/SITE,CoODE 1�3 1 PROGRAM/ELEMENT COMP # �' (�jZ �� LOC COD"RESPONSE <br /> UGT FILE X PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELLSOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT <br /> LEAD AGNCY/UNIT SJ/EH CON OHS CONTACT - <br /> OTHER CONTACT R B CONTACT WDR issued Y / N NPDES issued Y / N <br /> FAILED PT /7 j SOIL NT n ✓ GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 12- / #2 #3 94 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP MPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME 64kt ptZoN S 66VOR,4�-, S > <br /> ADDRESS / O CO '/Q D / <br /> CITY / O� /7✓ i1G STATE 6-- ZIP <br /> CONTACT NAME J �1 /7 D PHONE <br /> PROPERTY OWNER OI .SA O <br /> COMPANY NAME PHONE <br /> 1 <br /> CONTACT NAME T D fq PHONE <br /> ADDRESS {1 <br /> CITY lz" STATE G 2IP <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 # DATE / 7�/ _G/'/ PROP 65 # DATE /Z Q PRIORITY <br /> STREET # /Z 75 D SITE /STREET DO __/ �p/ f�AP/N # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CrqWR2 /` ," �./ o✓ <br />