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PHS/SAN JOACUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE 0-Base MFR - INPUT FORM <br /> UPOATE / / _1REVIEWED BY: vL DATE ENTERED: AUG 1 q 1993 BY: <br /> SWEEPS/SITE E C�3 r,. OGRAM/ELEMENT I COMP LOC/CODE JOIST 3d -� <br /> 6mAi� � <br /> UGT FILE PILOT FILE H V FILE SITE' MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> TSOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE I OTHER AGENCY REPORT I EMERGcNCY RESPONSE <br /> LEAD AGNCY/UNIT P�S r N A SJ/EH CONTACT OHS CONTACT -- <br /> OTHER CONTACT I TR.%AC3 CONTACT 11.I)R issued Y / N HPOES issued <br /> FAILED PT I SOIL CCNT 6/a /y GW CONT I OW CONT PETROLEUM Y / H J <br /> SUBSTANCEI �1 �—Ci+ "2 I 103 I "G I �'5 <br /> PRIOR FAILED PT NO ACTION I JCLEAN UP COMPLETE FDA 7ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5/ 6 DATE" ACTION TAKEN: <br /> SITE NAME I >� C�yfQ �C w �F l[n dLt S�7 "4 .Surr <br /> ADDRESS I /a O y f- /-z') e- eq <br /> CITY I Slz�n STATE ZIP cJ S 2 J <br /> =N TACT NAME I �C�7 U <e� I PHONE Gr y —6, 7?5' <br /> PROPERTY OWNER <br /> CCMPANY NAME PHONE <br /> CONTACT NAMEI PHONE `t G 7.:1 j <br /> c-e 4 4- - <br /> ADDRESS I �3 YL f�Ci•v i c> U JG L_!% f <br /> / 7 ATE C I ZIP <br /> CITY 5-1,C.IC./�r1 STuj <br /> RESPONSIBLE PARTY (If different from Property Owner) n <br /> COMPANY NAME A-c PHONE I O <br /> CONTACT NAME I PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> UAR : DATE PROP 65 x y?����.—'PATE PRIORITY <br /> STREET 2 SITE STREET ( �� �� �N 51-/ C1� —��� <br />