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•' PHS/SOAOUIN COUNTY - ENVIRONMENTAL HEALTH DIVISIO <br /> CONTAMINATED SITE O-Base MFR - INPUT FORM <br /> UPDATE: 3 Q5 / Y/ BY:rkj REVIEWED BY: L,v DATE ENTERED: / /!n/ BY: <br /> SWEEPS/SITE CODE J /n� PROGRAM/ELEMENT a3° �Y��CCMP # FtjCol?j LOC CODE 9 DIST'# <br /> UGT FILE PILLOT FILE N W FILE SITE MITIGATION PWS FILE PRIV WELL FILE [ ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT T EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT -- <br /> OTHER CONTACT RWOCS CONTACT WOR issued Y / N NPDES Issued Y / N <br /> FAILED PTSOIL CONI 3—a-5— ! GW CONT DW CONT ETROLEUM G/ N <br /> SUBSTANCE #1 02 #3 1 1 94 #$ <br /> PRIOR FAILED PT I yf`O ACTION CLEAN UP COMPLETE DATE 7ENNFFORCE14ENT ACTION Y / N <br /> ENFORCEMENT TYPE:O1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS v/ c <br /> CITY Sr /e-y- / STATE C� 21P <br /> CONTACT NAME ' v ' v PHONE mon) p3/- 373 ' <br /> PROPERTY OWNER <br /> COMPANY NAME S`-�//� /b C ° PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE 21P <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 # 9l_ 111 DATE 3_a5_ ql PROP 65 # (A''_ � DATE 3-as-�7 PRIORITY <br /> STREET Al / C/rs SITE STREET w t I APN 0 <br /> EN 23 070 (7/89)REVISED 03/91 89-19(IV) C4TMFR2 <br />