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PHS/S`OADUIN COUNTY - ENVIRONMENTAL HEALTH DMS., <br /> CONTAMINATED SITE-D-Base MFR - INPUT FORM <br /> -UPDATE: / / BY: REVIEWED BY: DATE ENTERED: /�.� / BY: <br /> SWEEPS1./SITE CODE PROGRAM/ELEMEN COMP # LOC CODE �� DIST # 3� <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> i .LEAD AGNCY/UNIT. SJ/EH CONTACT L-n gyp` DHS CONTACT <br /> OTHER CONTACT, RWOCB CONTACT WOR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONTpl/Z/l GW CONT OW CONT ETROLEUM / N <br /> SUBSTANCE #1 #2 93 1 % #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> E)IGORCEMENT TYPE: 1 2 3 6 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> A�ORESS Y I ' <br /> OppS • G tW' <br /> CITY Z,t;,4 STATE ZIP <br /> 4ONTALT NAME /�L it .1� I PHONE <br /> PROPERTY OWNER KT, J lam/ 7 <br /> COMPANY NAME / N I PHONE <br /> CONTACT NAME ►1 PHONE J <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 PIIONE <br /> ,UAR 0 DATE PROP 6ft # � DATE,�� PRIORITY <br /> STREFT # SITE STREET APN # <br /> EM 23 O7O (7/89)" 89-.191CIV) CNTMFR2 REVISED 12/94 <br />