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PHS/SAN j0A0UIN COUNTY • ENVIRONMENTAL HEALTH DIVISION ' <br /> CONTAMINATED SITE D-Base MFR INPUT FORM <br /> UPDATE: / / BY: REVIEWED BY: DATE ENTERED: /a/ Q3 / BY: <br /> ► �� LOC CODE] L�- DIST # 3 <br /> SWEEPS/SITE CODE PROGRAM/ELEMENT COMP # <br /> UGT FILE PILOT FILE tH W FILE SITE MITIGATION PWS FILE 1 7P <br /> RIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O Q FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT 1s A�LSJ/EH CONTACT r�(�(,(�� IONS CONTACT ^' <br /> OTHER CONTACT RWOCB CONTACT WDR issued Y / N NPDES issue / N <br /> FAILED PT SOIL CONT GW CONT DW CONT ETROLEUM Y / N <br /> U #2 #3 #4 #5 <br /> SUBSTANCE #1 Ion <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONTACT NAME ` ``" PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME Q — PHONE <br /> CONTACT NAME " PHONE <br /> ADDRESS (-7 t 1 � " � _ <br /> CITY l 1 STATE ZIP <br /> 5-2 <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 /> ��,,��(( L <br /> LIAR # V! ►AU I DATE (� 1 PROP 65 # a �� �� DATE I �\ H � PRIORITY <br /> STREET # lJ VV�C{( lt SITE STREET 11 APN # <br /> EH 23 070 (7/89)' 89-19(IV) CNTMFR2 REVISED 12/94 <br />