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PHS/ JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVI //�� <br /> SITE D-Base MFR - INPUT FORM —p( �� � Q�6OONTAMINATED 6 <br /> UPDATE: 12- BY: REVIEWED DATE ENTERED: �Z / -/ [ BY: LB <br /> SWEEPS/SITE CODE Gj 1 y PROGRAM/ELEMENT 2 9 �p Q COMP # LOC CODE0/ DIST # 3 2 Z <br /> UGT FILE IPILOT FILE H W FILE SITE MITIGATION WS FILE PRIV WELL FILE ENV ASSESS <br /> P <br /> SOLID WASTE H2O Q FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT IEMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT /A/,rU e�v q DHS CONTACT - <br /> OTHER CONTACT FRWQCB CONTACT WDR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONT .� - GW CONT DW CONT ETROLEUM © / N <br /> SUBSTANCE #1 2-0 3 92 �� #3 94 #5 <br /> PRIOR FAILED PT NO ACTION7 CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME RP 4* �` <br /> ADDRESS / ! j�jC C�i7 L/IAV(r <br /> Z to <br /> CITY 570 7-0N STATE (JA ZIP <br /> CONTACT NAME PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME �i`� C,D ¢n/ PHONE <br /> CONTACT NAME • T/¢ PHONE <br /> ADDRESS <br /> CITY ! STATE �� ZIP <br /> RESPONSIBLE PARTY (if different from Property Owner) [[! <br /> COMPANY NAME O� �D PHONE / <br /> CONTACT NAME �Qix.Z�a- PHONE 716 • ��' �P/l/ <br /> ADDRESS <br /> CITY Cid STATE CJ I ZIP !�(O <br /> CONSULTANT T�P�� / /• T 1 PHONE <br /> UAR # ! r a113 DATE PROP 65 # (� / / / DATE l�� � PRIORITY O / <br /> STREET # ! /--) 0 (0 <br /> �0 ( SIT E STREET /�J1/J/! !�// O O APN # �D // 0 O <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 ,•cT�—t/ l�P <br />