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PNS/�d JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISST3 <br /> CONTAMINATED SITE D-Base MFR INPUT FORM <br /> UPDATE: / /qq BY: REVIEWED BY: DATE ENTERED: ;` L� <br /> SWEEPS/SITE CODE PROGRAM/ELEMENT aC,S3 COMP # LOC CODE DIST # <br /> UGT FILE PILOT FILE N W FILE SITE MITIGATION PUS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O Q FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT `� 5 � ') SJ/EH CONTACT s G S S�Y� JDHS CONTACT <br /> OTHER CONTACT 1 ((( RWQCB CONTACT WDR issuedj Y / NPDES issued Y / <br /> FAILED PT SOIL CONT GW CONT DW CONT IP <br /> ETROLEUM Y / <br /> SUBSTANCE #1 / #2 #3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME G�GGfI L/h� J�(f' Id4/11 1/ jrn / G((C [` <br /> ADDRESS <br /> CITY / O„/, STATE C� ZIP <br /> =CONTACT C./ C%vl_ 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 'L r !_„�„ �.. J nJ I .�, /��� PHONE 5714-/ <br /> � �J <br /> UAR # DATE PROP 65 # - DATE PRIORITY <br /> STREET # SITE STREET TAPN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />