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PHS/SA AOUIN COUNTY - ENVIRONMENTAL HEALTH DIVISIC <br /> CCuNTAMINATED SITE O-Base MFR - INPUT FORM <br /> UPDATE: / / 'L/ / 9'Z-BY: Z,R VIEWED BY: bt) DATE ENTERED: �� /�(� /�� BY: � <br /> SWEEPS/SITE CODE 1PROGRAM/ELEMENT -i�� COMP p y LOC CODE �j DIST x ✓/1/ <br /> t`/,e, L v 7 <br /> UGT FILE PILOT FILE F H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASS'c 55 <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SVEH CONTACT OHS CONTACT - <br /> OTHER CONTACT RW!OC8 CONTACT WOR issued Y / N NPOES issued <br /> FAILED PT SOIL CONT I-IJ <br /> GW CONT DW CONT ETROL-e UM Y / N <br /> SUBSTANCE #1 I Za 7 :2 #3 94 #5 <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 /' AJ y/. ." <br /> ADDRESS <br /> CITY Y� —/- STATE � ZIP <br /> CONTACT NAME p - / 11 n F �. / PHONE �5` �71��O <br /> PROPERTY OWNER /_ / <br /> COMPANY NAME PHONE -y�_O�/�_f7f,�2 <br /> CONTACT NAME `N v _ _ / PHONE <br /> ADDRESS - -2- fO /j/[/NO ON <br /> CITY S�/ v IPA/w o /Xi STATE ZIP q[7L <br /> RESPONSIBLE PARTY (If different from Property 0~) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> UAR # _ DATE 92/L�Z. PROP 65 # _ DATE /-7/� P IORITY <br /> STREET 9 iD3 SITE STREET f/e,� `J s� /�� APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CHTMFR2 �^ J <br />