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PHS/S'�OACUIN COUNTY - ENVIRONMENTAL HEALTH DIVISIu. <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> J <br /> ,7/,� f ( ] BT:,IK/)yI REVIEWED BY: DATE ENTERED: /)Z / BY: <br /> UPDATE: ��/jn� <br /> C)r) <br /> p +� q(� LDC CODE DIST x <br /> SWEEPS/SITE CODE �3 O PROGRAM/ELEMENT 3, VII COMP x <br /> UGT Ffl_ <br /> PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE <br /> CC OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> SJ/EH CONTACT �U� J5,1 1 DNS CONTACT _ <br /> LEAD AGNCY/UNIT h Cy <br /> OTHER CANTACi R40CB�CCN7ALT WOR issued Y / N NPO ES issued Y / N <br /> FAILED PT IJ^f n SOIL CONT 0 GW CCNT Du CONT ETROLEUM 7 / N <br /> / x5 <br /> SUBSTANCE #1 V3� x2— x3 x4 <br /> PRICR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 0 2 3 6 5 6 DATE ACTION TAKEN: <br /> SITE NAME cX� <br /> ADDRESS <br /> CITY o� STATE C ZIP <br /> L <br /> CONTACT NAME �,(� <br /> t ) ' I '^ • , , r PHONE �a01 931 - 187 zf <br /> �y,��(/j/ IJ <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHCNE <br /> ADDRESS <br /> CITY STATE ZIP <br /> RESPONSIBLE PARTY (If different from Property Omer) <br /> COMPANY NAME C�/� „M PHONE <br /> CONTACT NAME v ' PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> UAR Al Qa-(,kl4 DATE '�_ 9- f( **PR�1OPP 65 x �� _ /37. , DATE ��D_.9a,, PRIORITY <br /> STREET 9 9'� SITE STREET {_{., t� APM R 0?A 070 Q' <br /> EN 23 070 (7/89)REVISe0 03/91 89-19(IV) CHTMFR2 / , , <br />