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I PRIoR..14//qc 17 <br />UPDATE: / / <br />PH.JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIV 4 <br />CONTAMINATED SITE 0-Base MFR - INPUT FORM <br />BY: PV <br />REVIEWED BY: DATE ENTERED: q <br />I <br />BY: / <br />99 DIST/# 32 SWEEPS/SITE CODE /7&0 PROGRAM/ELEMENT 27_3 .8 () COmP # fiti4 -7-ER 43 FLOC CODE <br />UGT FILE I PILOT FILE H W FILE [SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br />SOLID WASTE H20 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br />LEAD AGNCY/UNIT SJ/EH CONTACT OHS CONTACT - <br />OTHER CONTACT RWOCS CONTACT UDR issued Y / N NPOES issued Y / N <br />FAILED PT SOIL CONT q/ L.//9 c OW CONT OW CONT I PETROLEUM OV N <br />SUBSTANCE #1 , -7 <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 />SITE NAME 7t- h ell c(-41 on <br />ADDRESS Li 1 L-3 1,t)t6t-e-Y-Loo fq O\- <br />CITY 5-ft%C,K .\() <br />STATE (7,0 ZIP 6152C-7 <br />CONTACT NAME 1/t) ( 1 1 ((Lim A( ,',:y- bA4 PHONE 7/...,&.(,2 _. 673)/ -• <br />PROPERTY OWNER <br />COMPANY NAME <br />I ....5 hem (D i 1 (Ziy\_00_,y-tAt PHONE <br /> <br />CONTACT NAME <br />; <br />PHONE <br />ADDRESS 9D, 6ox '-)SL-18 <br />CITY Pli-heify) STATE C P ZIP 9 28 O 3 <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 # 6-1.0....u6, 5 DATE (-1 / s--1 q.6 PROP 65 # 9 0-0g6 DATEt &44.-7 -,, 7 PRIORITY <br />STREET # L./ 3 / 5 SITE STREET c/0a 4K/ c.°cc 10- APN 4 <br />EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2