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PIIS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE D-Base MFR INPUT FORM <br /> UPDATE: J / �j / '�BY: j REVIEWED BY: ` DATE ENTERED: / / B <br /> SWEEPS/SITE/ CODEJ PROGRAM/ELEMENT COMP # LOC CODE DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PUS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT 7EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT ��/ ,11N DHS CONTACT <br /> OTHER CONTACT TRWQCB CONTACT GL—f� [WOR issued Y / N NPDES issued FY <br /> / 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 /> EIIFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME T <br /> ADDRESS <br /> Z NC <br /> CITY `T'h�,�n_I_ � STATE �' -� ZIP <br /> 1 <br /> CONTACT NAME ` � 1 ► ����( � PHONE <br /> PROPERTY OWNER 1 l h <br /> COMPANY NAME rLzt PHONE <br /> CONTACT NAME 1 I Cr l� ' ( T L '�U PHONE <br /> ADDRESS ( \ L <br /> CITY ��/T I J STATE ZIP <br /> RESPONSIBLE PARTY (if different from Property Owner) U 1 t <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> rce <br /> CONSULTANT PHONE <br /> ,t qt <br /> UAR # DATE ;kA <br /> ROP 65 # DATE PRIORITY <br /> STREET # SITE STREET APN # `�DEH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 ` <br />