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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br />CONTAMINATED SITE D -Base MFR - INPUT FORM <br />UPDATE: % / /q 7 BY: { N y REVIEWED BY: DATE ENTERED: / / BY: <br />SWEEPS/SITE CODE <br />-,4/a 3 /4 <br />PROGRAM/ELEMENT <br />COMP # <br />LOC CODE <br />L <br />DIST # <br />Livlt'�" 3 h <br />UGT FILE <br />✓ <br />PILOT FILE <br />#1 <br />H W FILE <br />SITE MITIGATION <br />PUS FILE <br />#3 <br />PR1V WELL FILE <br />Y / N <br />Y / N <br />ENV ASSESS <br />#5 <br />SOLID WASTE <br />PRIOR FAILED PT <br />H2O a FILE <br />NO ACTION <br />EPI FILE <br />CLEAN UP COMPLETE <br />LAND USE FILE <br />DATE <br />OTHER AGENCY REPORT <br />ENFORCEMENT ACTION <br />EMERGENCY RESPONSE <br />FAILED PT <br />-,4/a 3 /4 <br />SOIL CONT <br />/�/( <br />GW CONT <br />L <br />LEAD AGNCY/UNIT <br />Livlt'�" 3 h <br />SJ/EH CONTACT <br />�l�g�$LOkQ- <br />DHS CONTACT <br />#1 <br />OTHER CONTACT <br />l 1C'GnG" GQ�m <br />TR <br />TRWQC8 CONTACT <br />#3 <br />issued <br />TWLR issued <br />Y / N <br />Y / N <br />NPDES issucd <br />NPDES issucd/ N <br />FAILED PT <br />-,4/a 3 /4 <br />SOIL CONT <br />/�/( <br />GW CONT <br />L <br />DW CONT <br />1PETROLEUM <br />ADDRESS <br />Y / N <br />SUBSTANCE <br />#1 <br />U 3 t #2 <br />l 1C'GnG" GQ�m <br />STATE <br />#3 <br />ZIP <br />#4 <br />CONTACT NAME <br />#5 <br />PHONE <br />PRIOR FAILED PT <br />NO ACTION <br />CLEAN UP COMPLETE <br />„/ <br />DATE <br />I (O /3 /Q -+- <br />ENFORCEMENT ACTION <br />Y / N <br />ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br />SITE NAME <br />C n:L%- O�GIO-IM <br />lYl �lr�� O/✓1 <br />PHONE <br />/�/( <br />ADDRESS <br />-4UOc> '�S. MlCl1�U 'nits J�IVQ. <br />PHONE <br />2a- <br />ADDRESS <br />Z (= Wc bcv - u <br />CITY <br />ck <br />CITY <br />l 1C'GnG" GQ�m <br />STATE <br />CA <br />ZIP <br />APN # <br />CONTACT NAME <br />Crat Q 0-+ <br />PHONE <br />PROPERTY OWNER 1--J U <br />COMPANY NAME <br />_ u� a 1 <br />C -0 <br />PHONE <br />/�/( <br />CONTACT NAME <br />c� I S l S l\ <br />e I <br />PHONE <br />2a- <br />ADDRESS <br />Z (= Wc bcv - u <br />CITY <br />ck <br />STATE <br />`-.Ucx� <br />ZIP <br />�� �c z - <br />RESPONSIBLE PARTY (If different from Property Owner) <br />COMPANY NAME <br />G _LIS I <br />_1 <br />PHONE <br />/�/( <br />CONTACT NAME <br />PROP 65 # <br />PHONE <br />2a- <br />ADDRESS <br />/ <br />CITY <br />STATE <br />`-.Ucx� <br />ZIP <br />s, M(6 -)G O` <br />CONSULTANT PHONE <br />UAR# <br />G _LIS I <br />_1 <br />DATE <br />/�/( <br />PROP 65 # <br />9 r_ <br />2a- <br />DATE <br />/ <br />PRIORITY <br />STREET # <br />`-.Ucx� <br />SITE STREET <br />s, M(6 -)G O` <br />C'OYSis —tWA <br />APN # <br />EH 23 070 (7/89)" 89-19(IV) CNTMFR2 REVISED 12/94 <br />