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PHS/:y JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVIS� <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: �,/� �/ BY: VZ REVIEWED BY: Vd DATE ENTERED: / / ' BY: <br /> SWEEPS/SITE CODE CCC � PROGRAM/ELEMENT I 0-71 CCMP # µn -Rr d 1 LOC CODE 9 q DIST 3 a <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE I ENV ASSESS <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 ,-�l m /(71L_UWDR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT o` GW CONT OW CONT ETROLEUM Y / N <br /> SUBSTANCE #1 l 0 7 1 #2 1 #3 1 #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y "0/ <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS <br /> CITY (fl�o_J �C 1✓/L, )// � STATE �- ZIP � a65 <br /> CONTACT NAME Tj, �.(J fK` J� PHONE <br /> PROPERTY OWNERt- <br /> COMPANY NAME L1 PHONE <br /> / 1INA ra4,6 <br /> q J <br /> CONTACT NAME I/ '1 !'T _�i j2� PHONE C5�3 �ii3�� /L/�ZI <br /> ADDRESS 1606 Vl/ J ( � F <br /> CITY STATE IOR ZIP ! 3 <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> OMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> UAR # GC� DATE s- PROP 65 # DATE /L' �� F/ PRIORITY <br /> STREET #/ JC-�1'' SITE STREET /J /�/ S' /��(�Q.� APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />