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PHS, JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DTVI <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / /(i/ BY: / REVIEWED BY: DATE ENTERED: /�/ / 9 J BY: <br /> SWEEPS/SITE CODE L�� PROGRAM/ELEMENT 2 COMP # / LOC CODE O DIS # <br /> i <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS 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/UNITS SJ/EH CONTACT 2r�f� DHS CONTACT - <br /> OTHER CONTACT RWQCB CONTACT F <br /> WDR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONT GW CONT DW CONT ETROLEUM V / N <br /> SUBSTANCE #1 12 f) #2 #3 #5 <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 7 <br /> CITY 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 li / 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 />