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PHS/SAfti.04UIN COUNTY - ENVIRONMENTAL HEALTH DIVISIO%w <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: `�I / �(�/ �I BY: �1 REVIEWED BY: DATE ENTERED: '?1 !2q BY: <br /> BY: <br /> SWEEPS/SITE CODE v���3 PROGJRAM/ELEMENT �3� COMP # LOC CODE DIST # <br /> EUGTILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRfV WELL FILE ENV ASSESS <br /> WASTE H2O 0 FILE EPI FILE I LAND USE FILE OTXER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT - <br /> OTHER CONTACT RWOCS CONTACT WOR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONT GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 #2 #3 'W' #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 ^ r <br /> ADDRESS —Ao <br /> CITYJ!� G v� STATE ZIP <br /> CONTACT NAME VL PHONE <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 PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> UAR # DATE PROP 65 # DATE PRIORITY <br /> STREET # --� 0-7 `� 11 SITE STREET APN # <br /> EN 23 070 (7/89)REVISEO 0`33/91 89-19(IV) CNTMFR2 <br />