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PHS/SAN%OUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE 0-3ase MFR - INPUT FORM <br /> UPDATE: / /%jamBY: Gi" REVIEWED BY: DATE ENTERED: I DI, Pu BY: <br /> SWEEPS/SITE SCODE 2V,56�� PROGRAM/ELEMENT '115, (� COMP # ��� _ LOC CODE Z DIST <br /> # 7 <br /> UGT FILE A, PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE! H2O O FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT `-lj _ <br /> </ SJ/EH CONTACT �� �����'�J DHS CONTACT - - <br /> OTHER CONTACT RWOCS CONTACT WVR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONT �� �- q� GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 /,7 CJ ,-�Z #2 43 #L #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: '1 2 3 4 S 6 DATE ACTION TAKEN: <br /> SITE NAME l7 <br /> ADDRESS / -J <br /> CITY /„� . _ STATE �� ZIP C-�,z `. <br /> CONTACT NAME /�- G������ PHONE '�'�C3/ <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY /LA 1( a' STATE . ZIP ��ZU <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> C^N SUL TANT / PHONE <br /> UAR # 12 - �� . DATE f�� CrL PRCP 65 # UGZ, DATE zv PRIORITY <br /> STREET # SITE STREET /G �� APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />