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PH! JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIV I <br /> CONTAMINATED SITE -Base MFR - INPUT FORM <br />' UPDATE: �- / BY: REVIEWED BY: DATE ENTEREDf,-EE <br /> SWEEPS/SITE DE �'Q£SS�{/ PROGRAM/ELEMENT c4, 3 COMP # LOC CODE r DIST # n� <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PUS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O Q FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT 1 14 DHS CONTACT - <br /> r <br /> OTHER CONTACT RWQCB CONTACT WOR issued FY <br /> / N NPDES issued Y / N <br /> FAILED PT SOIL CONTy/i 3 T S GW CONT j,/ (C S DW CONT ETROLEUM I Y / N <br /> SUBSTANCE #1 �oU�o�: #2 93 1 I #4 #5 l <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 4, ` <br /> ADDRESS �� J <br /> CITY n , w 1 S STATE ICA ZIP <br /> CONTACT NAME •CIvC �\v� PHONE b <br /> PROPERTY OWNER <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 �T .4OA- O . .A U� PHONE <br /> CONTACT NAME bo), D PHONE <br /> ADDRESS ��J <br /> CITY )L STATE I CA IZIP <br /> —7CONSULTANTGam(. h PHONE f>_i`/Z, <br /> UAR # DATE PROP 65 # DATE I y r PRIORITY <br /> STREET �SS# SITE STREET APN #80 f�..e,Q SSS � Zoo -03 <br />' EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />