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PHS/S CUIN COUNTY - ENVIRONMENTAL HEALTH DIVISII, <br /> . AMINATED SITE O-Sase MFR INPUT FORM <br /> UPDATE: / /{ /cFilBY: LC",7• REIIEUED BY: 1 " (;t-t7X7E CENTERED: (,iy/� / yy 8Y: <br /> 7777 <br /> SWEEPS/SITE CODE /d�P PROGRAM/ECE'E`1T �j• �� CGIp � LOC CODE o' 0[S7 X .'7`J'�'/�`� <br /> UOT FILE PILOT FILE H U FILE I SITE MITIGATION PUS FILE PRIV WELL FILE ENV ASSESS`--- <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT - OHS CONTACT -- <br /> OTHER CONTACT I RWQCB CONTACT WOR issued Y / N NPOES issued Y / 4 <br /> FAILED PT SOIL CONT 9 /(� cr GW CONT OW CONT ETROLEUM � N <br /> SUBSTANCE X1 3 92 I GGG x3 :5 <br /> PRICR FAILED PT NO ACTION CLEAN IP COMPLETE DATE ENFORCEMENT ACTION <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADORESS <br /> CITY STATE r-•[� ZIPr-i52D <br /> CONTACT NAME G Y PHONE <br /> � ,ems Gni/ <br /> PROPERTY CWNER <br /> COMPANY NAME Imo_ PHONE <br /> CONTACT NAME /r\I PHONE <br /> op� <br /> ADDRESS 3807 <br /> CITY /_ 1 STATE ZIP Z b <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CCNSULTANT PHONE <br /> UAR 9 y,��9 DATE PROP 65 X // DATE 9 l3 9 PRIORITY <br /> STREET R 3GO.7 S1TE STREET I C'd� 7I ,� „T APN 9 <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />