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PNS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: 3 / / BY: REVIEWED BY: DATE ENTERED: /� / �� BY: C . <br /> SWEEPS/SITE CODE PROGRAM/ELEMENT / 5c,)EEE <br /> LOC CODE DIST # <br /> ----[UGT FILE PILOT FILE �� H W FILE SITE MITIGATION PUS FILE PRIV WELL FILE I ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILELAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT //� DHS CONTACT <br /> OTHER CONTACT RWOCB 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 f #3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> EIIFORCEMENT TYPE: 1 2 3 4 5 /'6 DATE ACTION TAKEN: <br /> SITE NAMEf \V� <br /> ADDRESS <br /> CITY � � /• V/ l STATE -1 ZIP <br /> CONTACT NAME , 1 l PHONE ` <br /> PROPERTY OWNER Ilrr <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 PROP <br /> I 65 # C1 I Y jZ DATE ( a�/-4/ PRIORITY <br /> STREET # SITE STREET APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 l <br />