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PHS/SA,.AQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISIC� <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM r/ <br /> UPOATE:/0 BY: f REVIEWED BY: DATE ENTERED: �O / a0 / CJ� BY: 5� <br /> SWEEPS/SITE CODE U (j U Q PROGRAM/ELEMENT Z� I COMP # LOC CODE 9 DIST At 5z— <br /> UGT FILE PILOT FILE H W FILE X 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 CONTACTE�L rp�c�,� DHS CONTACT - - <br /> OTHER CONTACT RWOCB CONTACT WOR issued Y / N NPO ES issued Y / N <br /> FAILED PT SOIL CONT �O (l� GW CONT OW CONT ETROLEUM Y / N <br /> SUBSTANCE 91 /,?c> #2 #3 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 NAME <br /> 1 4— <br /> ADORSSS <br /> CITY D 1 STATE ZIP <br /> CONTACT NAME GGGV���111 PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME ! G PHONE / ) 7TZ <br /> CONTACT NAME PHONE -772-- 1101 <br /> /mo <br /> ADDRESS D . o <br /> CITY .?v SD STATE ZIP 9�2 z <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 # �� SITE STREETv�'� ! APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 �y <br />