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PHS/S,.,,�OAOUIN COUNTY - ENVIRONMENTAL HEALTH DM S <br /> `i <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: // / / ! BY: REVIEWED BY: DATE ENTERED: / S 1 / '71 BY: <br /> SWEEPS/SITE CODE 1 D y PROGRAM/ELEMENT a 3 COMP # co�r"' J� f 1(((FLOCCODEO/ T # 3a l <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE I / /PRIV WELL FILE ENV ASSESS d_ <br /> SOLID WASTE H2O O FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT -- <br /> OTHER CONTACT RWOCB CONTACT WDR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 #2 #3 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE /3 9i ENFORCEMENT ACTION Y N <br /> ENFORCEMENT TYPE: 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS / U <br /> CITY "sSTATE C/� 2IP -1 <br /> CONTACT NAME , V PHONE L f/„Q(&—5 7 / <br /> PROPERTY OWNER `v / <br /> COMPANY NAME `) <br /> PHONE <br /> i <br /> CONTACT NAMEa4PHONE � 0-1 (� <br /> q�/ -5 3 7 <br /> ADDRESS 5mh _ �I CJ's <br /> CITY STATEC 2IP <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 # / / /p SITE STREET ppN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />