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LEAD AGNCY/UNIT �T DHS CONTACT <br />OTHER CONTACT R40CB CONTACT WOR issued Y / N NPDES isso_d . / N <br />F <br />EFAILEDPT SOILCONT GW CONT DW CONT ETROLEUM Y / N <br />CE #1 17X3 S #2 #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 NAME <br />6a b �� (� Q�A.(. .Q �Y'fL S <br />��/\ , r ` <br />ADDRESS <br />O <br />CITY <br />STATE <br />6;6- <br />PIIS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br />D %� O <br />CONTACT NAME <br />6c,6 <br />PHONE <br />CONTAMINATED SITE D -Base MFR - <br />INPUr FORM <br />O <br />UPDATE: <br />/ / BY: <br />REV'EWED Y• <br />DATE ENTERED: /� <br />APN <br />BY: <br />SWEEPS/SITE CODE <br />PROGRAM/ELEMENT COMP # <br />D O <br />LOC CODE <br />DIST # <br />UGI FILE <br />PILOT FILE <br />H W FILE <br />I SITE MITIGATION <br />PUS FILE <br />PRIV WELL FILE <br />ENV ASSESS <br />SOLID WASTE <br />H2O 0 FILE <br />I EPI FILE <br />LAND USE FILE <br />OTHER AGENCY REPORT <br />EMERGENCY <br />RESPONSE <br />LEAD AGNCY/UNIT �T DHS CONTACT <br />OTHER CONTACT R40CB CONTACT WOR issued Y / N NPDES isso_d . / N <br />F <br />EFAILEDPT SOILCONT GW CONT DW CONT ETROLEUM Y / N <br />CE #1 17X3 S #2 #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 NAME <br />6a b �� (� Q�A.(. .Q �Y'fL S <br />��/\ , r ` <br />ADDRESS <br />O <br />CITY <br />STATE <br />6;6- <br />ZIP <br />D %� O <br />CONTACT NAME <br />6c,6 <br />PHONE <br />77 _337 <br />PRnPFRTY OLNFR <br />COMPANY NAME <br />6a b �� (� Q�A.(. .Q �Y'fL S <br />��/\ , r ` <br />PHONE <br />DATE <br />CONTACT NAME <br />PHONE <br />ADDRESS <br />D %� O <br />CITY <br />STATE <br />"�/ <br />✓/a <br />ZIP <br />O <br />4' <br />APN <br />RESPONSIBLE PARTY (If different from Property Owner) <br />COMPANY NAME <br />PHONE <br />DATE <br />CONTACT NAME <br />PHONE <br />ADDRESS <br />CITY <br />STATE <br />ZIP <br />COIISULTANT PHONE <br />UAR # <br />DATE <br />to / <br />I PROP 65 # <br />DATE <br />n <br />lob"/ <br />W <br />PRIORITY <br />STREET # <br />O <br />SITE STREET <br />APN <br />EH 23 070 (7/89)" 89-19(IV) CNTMFR2 REVISED 12/94 <br />