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PF, JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIO <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / / / GJ/ BY: REVIEWED BY: DATE ENTERED: / / BY; <br /> SWEEPS/SITE CODE / PROGRAM/ELEMENT �2 2 E �q DIST ZZ� <br /> UGT FILE LOP FILE H W FILE SITE MITIIGATION 114PWS FILE PRIV WELL FILE ! ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT <br /> �7Z � DHS CONTACT <br /> OTHER CONTACT RWVCB CONTACT WDR issued Y / N NPDES issued /Y�/ N <br /> FAILED PT / / SOIL CONT / �� / �/ GW CONT / / OW CONT PETROLEUM / Y I/ N <br /> SUBSTANCE #1 /_2 n #2 / #3 #4 #5 <br /> PRIOR FAILED PT NOACTIONCLEAN UP COMPLETE DATE / / ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME r <br /> 1 L <br /> ADDRESS <br /> / ro w <br /> CITY `-7 STATE ZIP <br /> CONTACT NAME / PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME / <br /> PHONE <br /> ADDRESS <br /> CITY <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME <br /> PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY .� STATE ZIP <br /> CONSULTANT '` <br /> JAR # I� DATE PRW 65 # DATE PRIORITY 7 <br /> STREET # / SITE STREET )r�CO0. /IG�Ll/Cl- APN # A15- <br /> ZSO- a5 <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />