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PHS, JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DTVI <br />CONTAMINATED SITE D -Base MFR - INPUT FORM <br />UPDATE:/ /9 BY: REVIEWED BY: DATE ENTERED: / �� / .,f BY: <br />SWEEPS/SITE CODE <br />i <br />PROGRAM/ELEMENT COMP # <br />y� <br />-,�b S O b i <br />LOC CODE <br />9 9 GIST 3a <br />UGT FILE <br />I C/� <br />PILOT FILE <br />/ N <br />H W FILE <br />SITE MITIGATION <br />Y / N <br />PUS FILE <br />Y / N <br />PRIV WELL FILE <br />ENV ASSESS <br />94 <br />SOLID WASTE <br />#5 <br />H2O 0 FILE I <br />EPI FILE <br />7LANO <br />USE FILE <br />OTHER AGENCY REPORT <br />EMERGENCY RESPONSE <br />LEAD AGNCY/UNIT <br />DATE <br />SJ/EH CONTACT <br />y� <br />-,�b S O b i <br />DHS CONTACT <br />'-7 v <br />OTHER CONTACT <br />I C/� <br />RWOCS CONTACT <br />/ N <br />SUBSTANCE <br />WDR issued <br />Y / N <br />NPDES issued <br />Y / N <br />FAILED PT <br />DATE <br />SOIL CONTI <br />y� <br />-,�b S O b i <br />GW CONT <br />'-7 v <br />DW CONT <br />I C/� <br />ETROLEUM <br />/ N <br />SUBSTANCE <br />#1 <br />#2 <br />(ao q ?3 - 3 a / b <br />ZIP <br />#3 <br />94 <br />#5 <br />PRIOR FAILED PT <br />NO ACTION <br />CLEAN UP COMPLETE <br />DATE <br />ENFORCEMENT ACTION <br />Y / N <br />ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br />SITE NAME <br />DATE <br />ADDRESS <br />y� <br />-,�b S O b i <br />CITY <br />'-7 v <br />STATE <br />I C/� <br />lzip <br />% 5'3 7 <br />CONTACT NAME <br />Zh <br />PHONE <br />(ao q ?3 - 3 a / b <br />PROPERTY OWNER v v <br />COMPANY NAME <br />DATE <br />PHONE <br />PROP 65 # <br />CONTACT NAME <br />V <br />PHONE <br />I PRIORITY <br />ADDRESS <br />STREETa0500 <br />CITY <br />SITE STREEThwjl!�, <br />STATE <br />APN # <br />ZIP <br />RESPONSIBLE PARTY (If different from Property Owner) <br />COMPANY NAME <br />DATE <br />PHONE <br />PROP 65 # <br />CONTACT NAME <br />DATE <br />PHONE <br />I PRIORITY <br />ADDRESS <br />STREETa0500 <br />CITY <br />SITE STREEThwjl!�, <br />STATE <br />APN # <br />ZIP <br />CONSULTANT PHONE <br />UAR # I <br />DATE <br />PROP 65 # <br />DATE <br />9/ <br />I PRIORITY <br />STREETa0500 <br />SITE STREEThwjl!�, <br />APN # <br />EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 U <br />