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PNS/-..,, JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVIb,-1 <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: ( / 3 /t?ZBY: REVIEWED BY: DATE ENTERED: /, �? / BY <br /> SWEEPS/SITE CODE 9Z 3 O PROGRAM/ELEMENT COMP # F--FLoc DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE 1120 Q FILE EPI FILET I LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT /�/� fRWQCB <br /> SJ/EH CONTACT //Jn _�/� DHS CONTACT <br /> OTHER CONTACT v'v CONTACT ,/,//7 N ,�-IIW/DRR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT GW CONT DW COAT IP <br /> ETROLEUM Y / N <br /> SUBSTANCE #1 #2 #3 #4 #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 /v <br /> ADDRESS 130 U N. /t&C w'�,Wt4x,4,, <br /> CITY STATE ZIP <br /> CONTACT NAME PHONE <br /> PROPERTY OWNER <br /> COMPANYNAME �� C PHONE <br /> CONTACT NAME D�/ £ $ PHONE f `tP ✓tel_ ��o U <br /> ADDRESS <br /> CITY STATE C� 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 # /3 g� SITE STREET I� APN # �Q_020, SZ <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />