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PHSWN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVIIN'TtSN <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> LIPOATE: 5 / / BY: REVIEWED BY: DATE ENTERED: / / BY: <br /> SWEEPS/SITE CODE D?j?, PROGRAM/ELEMENT Q COMP # LOC CODE 010 DIST # Z/ <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PUS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE 1120 0 FILE EPI FILE j LAND USE FILE OTHER AGENCY REPORT F)< JEMERGENCY RESPONSE <br /> LEAD AGNCY/UNITCU11GA 1,46 7— SJ/EH CONTACT �/v /Z/Z//Q DHS CONTACT <br /> OTHER CONTACT ((XX �✓ '! FRWOCB CONTACT ,00 <br /> 4,1 /S WDR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT 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 <br /> ADDRESS �7 t7 U ,,/� , ?i <br /> CITY ' !� Fs <br /> ATE ZIP gsa�j <br /> CONTACT NAMECs���y � �ilrt2 PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME �y PHONE <br /> CONTACT NAME l PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> RESPONSIBLE PARTY (1f differ t from Property Owner) <br /> COMPANY NAME /� n S PHONE <br /> CONTACT NAME !/j/f,J� e. �� (� S/1 Owe PHONE �Jr� O De) <br /> d'` <br /> ADDRESS , (lOO �i¢tL.�E2N O/1I /�-�GCJCJL #ZOO <br /> CITY N. STATE <br /> CONSULTANT /�f_./ a . / PHONE i/qd� &L <br /> UAR # DATE PROP 65 # DATE PRIORITY <br /> STREET # / OD SITE STREET <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />