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PHSi`/ JOADUIN COUNTY - ENVIRONMENTAL HEALTH DIVISII-� <br />CONTAMINATED SITE O -Base MFR - INPUT FORM <br />UPDATE: 8 / 7 / 9 ' BY: PV REVIEWED BY: DATE ENTERED: Q BY: - <br />LEAD AGNCY/UNIT <br />cl v� io <br />SJ/EH <br />CONTACT <br />GW CONT <br />DHS CONTACT <br />- <br />- <br />OTHER CONTACT <br />SWEEPS/SITE COD <br />I I <br />PROGRAM/ELEMENT <br />23 ,Q <br />CCMP # <br />Le- 1+00 LOC CODE <br />I <br />ol <br />DI # <br />' <br />l l <br />1 <br />PRIOR FAILED PT <br />C- <br />CLEAN UP COMPLETE <br />Z <br />UGT FILE <br />PILOT FILE <br />Y / N <br />H W FILE <br />SITE MITIGATION <br />PWS FILE <br />PRIV WELL FILE <br />ENV ASSESS <br />SOLID WASTE <br />H2O 0 FILE <br />EPI FILE <br />LAND USE FILE <br />OTHER AGENCY REPORT <br />EMERGENCY RESPONSE <br />LEAD AGNCY/UNIT <br />cl v� io <br />SJ/EH <br />CONTACT <br />GW CONT <br />DHS CONTACT <br />- <br />- <br />OTHER CONTACT <br />Y N <br />RWOCB CONTACT <br />#1 <br />IZ <br />WDR issued <br />Y / N <br />NPDES issued <br />Y / N <br />FAILED PT <br />cl v� io <br />SOIL CONT <br />e 2! _/I <br />I <br />GW CONT <br />DW CONT <br />! G4 <br />l// <br />ETROLEUM <br />Y N <br />SUBSTANCE <br />#1 <br />IZ <br />#2 <br />ZIP <br />#3 <br />1 <br />#5 <br />PRIOR FAILED PT <br />NO ACTION <br />CLEAN UP COMPLETE <br />DATE <br />ENFORCEMENT ACTION <br />Y / N <br />ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br />SITE NAME <br />t,"1 K horn Cou <br />ADDRESS <br />D�5D Drive - <br />CITY <br />STATE <br />! G4 <br />l// <br />2IP <br />�w�ZO61 <br />CONTACT NAME <br />DEO <br />/ : i D L_� <br />PHONE 2� �✓ y{�+ <br />PROPERTY OWNER <br />COMPANY NAME <br />vrj /I/tQ Q <br />w F <br />PHONE <br />S Z q I <br />CONTACT NAME <br />PHONE <br />8 2 a I <br />ADDRESS <br />CITY <br />DEO <br />STATE <br />K hor n <br />ZIP <br />APN # <br />RESPONSIBLE PARTY (If different from Property Owner) <br />COMPANY NAME <br />�n nnn /1 <br />�Y <br />PHONE <br />S Z q I <br />CONTACT NAME <br />PHONE <br />8 2 a I <br />ADDRESS <br />CITY <br />DEO <br />STATE <br />K hor n <br />ZIP <br />APN # <br />CONSULTANT PHONE <br />UAR # <br />\ATE <br />S Z q I <br />PROP 65 # <br />�1 , <br />DATE <br />8 2 a I <br />PRIORITY <br />STREET # <br />DEO <br />SITE STREET <br />K hor n <br />APN # <br />EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />