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PHS/t OACUIN COUNTY - ENVIRONMENTAL HEALTH DIVIS <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / �/ 92 BY: REVIEWED BY: DATE ENTERED: / By- <br /> SWEEPS/SITE CODE 7 Q PROGRAM/ELEMENT ay 50 COMP # LOC CODE D� DIST # <br /> UGT FILE LOP FILE v H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORTT-1 EMERGENCY RESPONSE <br /> LEAD AGNCY/UNITS SJ/EH CONTACT ti� DHS CONTACT <br /> OTHER CONTACT TRWQCB CONTACT WDR issued Y / N NPOES issued Y / N <br /> FAILED PT / / SOIL CONT / / GW CONT / / DW CONT PETROLEUM Y / N <br /> SUBSTANCE +PT <br /> #2 #3 #4 #5 <br /> PRIOR FAILENO ACTION CLEAN UP COMPLETE YI <br /> DATE / / JAZ ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS (-31,j <br /> CITY ` -'fes STATE ZIP <br /> CONTACT NAME !! PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME / PHONE <br /> CONTACT NAME v PHONE <br /> ADDRESS �Q <br /> CITY STATE ZIP �Sa� <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 # 1,>2/7/c) SITE STREET APN # a/3 r0 ;L7 <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />