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PL iN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DI--ON <br /> CONTAMINATED SITE D-Base MFR INPUT FORM <br /> UPDATE: � /A, /`'1 l� BY: p/ 7}1 REVIEWED BY: DATE ENTERED: 4PQ 14 i99J B <br /> SWEEPS/SITE CODE �� PROGRAM/ELEMENT19, COMP # LOC CODE DIST # �! <br /> UGT FILE LOP FILE H W FILE SITE MITIGATION 3% PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE TSE FILE OTHER AGENCY REPOR-F TTERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT �� DHS CONTACT <br /> OTHER CONTACT RWOCB CONTACT WDR issued Y / N NPDES issued Y / N <br /> FAILED PT / / SOIL CONT �' /2 s / GW CONT DW CONT PETROLEUM Y / N <br /> SUBSTANCE #1 0 c') (ijCij i l #2 #3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE / / ENFORCEMENT ACTION <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME ! A ( k <br /> ADDRESS <br /> CITY 1 STATE ZIP <br /> CONTACT NAME l� j PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME {� (� J PHONE <br /> CONTACT NAME ` PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> RESPONSIBLE PARTY (If different Fran Property Owner) <br /> COMPANY NAME %' j PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> UAR # DATE PROP 65 # I DATE �(� PRIORITY <br /> STREET # SITE STREET 4v 1 n t APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />