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PHS/SAN-'IAOUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> r AMINATED SITE D-Base MFR - INPUT FORM i <br /> UPDATE: / / �I BY REVIEWED BY: DATE ENTERED: BY: �\ <br /> SWE.15/SITE CODEf PROGRAM/ EMENT 7/3 2�r/ COMP S !� LOC CODE DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE / PRIV WELL FILE ENV ASSEeSS <br /> SOLID WASTE H2O a FILE £PI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> i <br /> ;i <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT -- <br /> OTHER CONTACT RtACB CONTACT =WDRued Y / N NPOES issued Y,' / N <br /> FAILED PT SOIL CONT �! / GW CONT DW CONT ETROLEUM YI / N <br /> SUBSTANCE "i R2. #3 . #4 #5^ <br /> /moo Z <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 /> SIT_ NAME 3A //7/QIT/1 �/i S�/2 ✓/c� ' <br /> 1k <br /> ADDRESS <br /> CITY STATES ZIP <br /> CONTACT NAME ! s PHONE 3 <br /> PROPERTY OWNER 1 <br /> COMPANY NAME A l? / PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS Q! x 0-7 0 <br /> CITY C.� G? STATE ZIP <br /> RESPONSIBLE PARTY (if different from Property Owner) <br /> COMPANY NAME /V Cie— PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY [STATE 2!P <br /> CONSULTANT PHONE <br /> 4 it <br /> VAR # ��J / G] DATE 9���- / JPRCP 65 0 DATE ����� PRIORITY <br /> STREET # !$ � 4j' <br /> SITE STREET /i � =APN # rJ � r'2,� <br /> Em 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFRZ <br />