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PH 'I JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIS `N <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: BY:BY: ' REVIEWED BY: DATE ENTERED: / _ /.'. BY;- <br /> SWEEPS/SITE <br /> Y:SWEEPS/SITE CODE / PROGRAM/ELEMENT "a " " COMP # LOC CODE .�( DIST # <br /> UGT FILE LOP FILE H W FILE SITE MITIGATION / PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O G FILE J_[EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT % SJ/EH CONTACT DHS CONTACT <br /> { <br /> OTHER CONTACT RWQCB CONTACT WDR issued Y / N NPDES issued Y / N <br /> FAILED PT / / SOIL CONT 7 / _ GW CONT / / DW CONT PETROLEUM 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 J h �r �r <br /> ADDRESS / <br /> / Ll <br /> CITY STATE Y -. ZIP <br /> CONTACT NAME PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> 4 <br /> CONTACT NAME / PHONE <br /> ADDRESS r� 71-3 /�//� v '4t, fJ <br /> CITY �`,',ty�n STATE ZIP/ �jfl`�S,` 3 <br /> r"\ V I <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 PRW 65 # DATE PRIORITY <br /> STREET # /" SITE STREET <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />