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✓ PH'. JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIV_ .J <br /> ONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: ?'12-1 /6)/ BY: REVIEWED BY: DATE ENTERED: / )-/ /17/ BY: <br /> SWEEPS/SITE CODE 9y3�J PROGRAM/ELEMENT COMP # LOC CODE 10?l DIST 3Z <br /> UGT FILE PILOT FILLEVE H W FILE SITE MITIGATION PWS FILE PRIVM <br /> ENV ASSESS <br /> SOLID WASTE H2O FILE EPI FILE 7LAND USE FILE OTHER AGENCY REPORTNCY RESPONSE <br /> LEAD AGNCY/UNIT /2 co(:zL J SJ/EH CONTACT G/G�� DHS CONTACT - <br /> OTHER CONTACT RWOCB CONTACT K WOR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONT GW CONT l0�.�9 DW CONT IP <br /> ETROLEUM Y / N <br /> SUBSTANCE #1 �� 70 Z #2 #3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTIONY / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME 5 <br /> ADDRESS o00 L►�. T/ 13A) <br /> CITY STATE /1"Al ZIP <br /> CONTACT NAME l' PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME �,, /� O J�?T3' � PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY / - STATE ZIP <br /> JO <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT G <br /> - PHONE 1.2 0 Z/ <br /> UAR # DATE PROP 65 # i�.�j�j DATE PRIORITY <br /> STREET # SITE STREET ((! ` (((/ APN # <br /> a� Zso-02-0 ' <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 Al JCC <br /> Z <br />