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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> BY: REVIEWED BY: DATE <br /> UPDATE: ENTERED: / r / BY: <br /> SWEEPS/SITE CODE=� <br /> 3d346 PROGRAM/ELEMENT COMP # LOC CODE DIST N <br /> dwgI --- <br /> PI LOT FILE H W FILE SITE MITIGATION -1 <br /> UGT FILE T PWS FILE PRIV WELL FILE ASSESS <br /> SOLID WASTE H2O Q FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT IEMERGENCY <br /> ENV ASSESS <br /> H W FILE SITE tf!!L" <br /> lHLE RESPONSE <br /> LEAD AGNCY/UNIT —7 —'SJ/EH <br /> CONTACT DHS CONTACT <br /> OTHER CONTACT RWQCS CONTACT issued Y / <br /> N NPOES iSSU-« N <br /> FAILED PT GW CONT <br /> SOIL CONT DW CONT ETROLEUM T�? <br /> SUBSTANCE #1 #2 #3 #4 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y N <br /> E11FORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME —f4,a"&f,4 A C-A 4FL.-9 0^1 <br /> ADDRESS <br /> CITYSTATE ZIP <br /> Z, vj/ <br /> LOW7-.-8 —I- <br /> TACT NAME -�5,4AJ PHONE <br /> — -- <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME 4A PHONE ci c"', <br /> ADDRESS /PJ Ae-!f-4 S-,*/ VA <br /> STATE i^i1 ZIP "�- <br /> Z�=� <br /> RESPONSIBLE PARTY (if different from Property Owner) <br /> COMPANY NAME PHONE <br /> 7 <br /> CONTACT NAME L,f -,e .1A't PHONE <br /> ADDRESS -7- VA <br /> oe4l-7 <br /> CITY I S-TATE JZIP <br /> 'ElU LTANT PHONE <br /> —s DATE P 61"'I'4pe <br /> UAR # _JDATE PRIORITY <br /> PROP 5 # <br /> P <br /> op 65 <br /> SITE STREET APN # <br /> STREET # e5 77 !!E <br /> EH 23 070 (7/89)- 89-19(IV) CNTMFR2 REVISED 12/94 <br />