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PHSAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIV ION <br /> ��, CONTAMINATED SITE D-Base MFR INPUT FORM <br /> UPDATE: S / /� BY: Lj.(� REVIEWED BY: DATE ENTERED: BY: / <br /> SWEEPS/SITE 1 PROGRAM/ELEMENT <br /> 401 •�I caM # LOC CODE DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PUS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O Q FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT <br /> OTHER CONTACT RWQCB CONTACT WDR Issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 #2 43 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE Y DATE 3 [ t [(� ENFORCEMENT ACTION Y / N <br /> EIIFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME A G _� V <br /> ADDRESS <br /> CITY w�� 1 STATE ZIP <br /> CONTACT NAME L "vv, PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> RESPONSIBLE PARTY (if different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> UAR # DATE iPROP 65 # DATE PRIORITY <br /> STREET # SITE STREET APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />