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PHS/SA,,.,AOUIN COUNTY • ENVIRONMENTAL HEALTH DIVISII,.� <br /> CONTAMINATED SITE D-Base MFR INPUT FORM <br /> UPDATE: (($9rx/1� BY: REVIEWED 8Y: i DATE ENTERED: /� ?� /� BY: V <br /> SWEEPS/SITE CODE ll(X O� PROGRAM/ELEMENT JK COMP ft LOC CODE DIST # / <br /> UGT FILE PILOT <br /> FILE H 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 EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT <br /> OTHER CONTACT RWOCB CONTACT WDR issued Y / N NPOES issued Y / N <br /> FAILED PT SOIL CONT GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE #t #2 1 #3 1 94 #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 NAMEyl .r �X�LLI,<t <br /> ADDRESS �d g V0 ( n '/1 <br /> CITY �y,..�, Iii_ STATE y,.J ZIP <br /> CONTACT NAME I / PHONE <br /> PROPERTY OWNER ��/� �' (�,(� <br /> COMPANY NAME �✓�.�. 1 t �U 1^-fC50�� HONE <br /> CONTACT NAME ( S -�� PHONE <br /> ADDRESS <br /> CITY STATE ' i. ZIP <br /> RESPONSIBLE PARTY (if different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CCNSULTANT PHONE <br /> UAR # DATE PROP 65 # DATE PRIORITY <br /> STREET # SITE STREET APN Al <br /> EN 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />