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PfIS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE 0-Base MFR - INPUT FORM <br /> UPDATE: 1/ /3o/G?/f BY: REVIEWED BY: DATE ENTERED: BY <br /> SWEEPS/SITE CODE / i�joc�J PROGRAM/ELEMENT 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 �H SJ/EH CONTACTL / /� OHS CONTACT <br /> OTHER CONTACT TRWQCB CONTACT L.�` WDR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT GW CONT OW CONT ETROLEUM Y / N <br /> SUBSTANCE +PT <br /> #2 #3 #4 #5 <br /> PRIOR FAILENO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME I <br /> ADDRESS \ — <br /> CITY �v STATE n ZIP <br /> CONTACT NAME V PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS ,r,/� <br /> CITY I STATE LSC/' `► 2IP G CJ <br /> RESPONSIBLE PARTY (if different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT EC n 0A PHON / -wad <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 �✓ v <br />