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P HSQ JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVIU <br /> A/CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: //`7 / / BY: REVIMD BY: DATE ENTERED: / /f 6Y: <br /> s- SWEEPS/SITE CODE PROGRAM/ELEMENT COMP # ;# LOC CODE D ID/1191 <br /> [ UGT FILE LOP FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> i <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE , <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT <br /> k <br /> OTHER CONTACT RWQCB CONTACT WDR issued Y / N NPDES issued Y / N <br /> FAILED PT / / SOIL CONT / / GU CONT / / Du CONT PETROLEUM Y / N <br /> t° <br /> SUBSTANCE #1 #2 #3 °{ #4 #5 <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 /> 4 <br /> SITE NAME <br /> f ADDRESS <br /> p <br /> CITY STATE C — ZIP <br /> ENTACT_NAME_ } PHONE <br /> # PROPERTY OWNER <br /> COMPANY NAMEA, <br /> PNOHEi7_6����/J-yl 1 <br /> CONTACT NAME G l PHONE <br /> A <br /> ADDRESS u 'O',"zo-006, <br /> CITY lop, <br /> STATE ZIP C1 3 ev <br /> < <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> E <br /> 'P <br /> COMPANY NAME I PHONE <br /> CONTACT NAME PHONE <br /> i <br /> ADDRESS <br /> CITY STATE TIP <br /> E <br /> ,k <br /> CONSULTANT PHONE <br /> ,1 <br /> :e <br /> UAR # DATE PROP 65 # DATE PRIORITY <br /> y <br /> !I STREET # 7 SITE STREET / f ,//„fin T <br /> PN # <br /> - 1 <br /> EN 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />