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PIIS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> � CONTAMINATED SITE D-8ase MFR - INPUT FORM <br /> /�1 `� <br /> UPDATE: / 2 BY: ,J4p REVIEWED BY: DATE ENTERED: —JUL 2 2 4993 BY: <br /> SWEEPS/SITE CODEI FPROGRAM/ELEMENT X69 COMP # LOC CODE DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PUS 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 SJ/EH CONTACT DHS CONTACT <br /> OTHER CONTACT RWOCB CONTACT WOR issued Y / N NPD ES issued Y / N <br /> FAILED PT SOIL CONT GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 #2 /#3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE Y DATE -7 ENFORCEMENT ACTION Y / N <br /> EIIF���OIIIRCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> vC'1 J <br /> r <br /> ADDRESS <br /> CITY I `lA STATE ZIP <br /> CONTACT NAME PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <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 PROP 65 # DATE PRIORITY <br /> STREET # SITE STREET APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />