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PH` JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIV' <br />CONTAMINATED SITE D•3ase MFR - INPUT FORM - <br />UPDATE: / /a Ll 8YI/11 EVIEUED 8Y: �� �':, ,� DATE ENTERED: /// a9/ %`� BY: n_ni <br />SWEEPS/SITE CODE <br />PROGRAM/ELE ENT <br />U <br />CCMP X <br />ADDRESS <br />LOC CODE <br />re Ue� <br />I <br />0[57 <br />STATE I ZIP <br />���"'��� JJJ <br />,,^ <br />c4lT I ZIP <br />CONTACT NMIE <br />I <br />Z � �_, �t-j��`i/. �-.1 .� ✓J,O S4/I <br />PHONE <br />sT /)�_ - � O� <br />STATE <br />ZIP <br />LOT FILE <br />PILOT FILE <br />H W FILE <br />SITE MITIGATION <br />PUS FILE <br />I <br />PRCV WELL <br />FILE <br />I <br />ENV ASSESS <br />SOLID WASTE <br />H2O O FILE <br />EPI FILE <br />LAND USE FILE <br />OTHER AGENCY <br />REPORT <br />I <br />EMERGENCY RESPONSE <br />LEAD AGNCY/UNIT i SJ/EH CONTACT �5 DHS CONTACT - - <br />OTHER CONTACT RWGCS CONTACT WOR Issued Y / N I NPOES issued Y / N <br />FAItFAILED <br />SOIL CONT A� y 'l GW CONT DW CONT PETROLEUM I Y,' / N <br />Su8Al2D 3 r .2 �I �3 I "4 I �5 <br />PRINO ACTION <br />I CLEAN UPCOMPLETE DATE ENFORCEMENT ACTION Y / N <br />ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKER: <br />PROPERTY OWNER <br />COMPANY NAME <br />RESPONSIBLE PARTY (If different from Property <br />10 C e <br />/ LLL///F-P�N---- <br />SITE NAME <br />CONTACT NAME <br />ADDRESS <br />) <br />ADDRESS <br />re Ue� <br />CITY <br />�/ I� �/ <br />�-'W <br />STATE I ZIP <br />���"'��� JJJ <br />,,^ <br />c4lT I ZIP <br />CONTACT NMIE <br />I <br />Z � �_, �t-j��`i/. �-.1 .� ✓J,O S4/I <br />PHONE <br />sT /)�_ - � O� <br />STATE <br />ZIP <br />PROPERTY OWNER <br />COMPANY NAME <br />RESPONSIBLE PARTY (If different from Property <br />10 C e <br />/ LLL///F-P�N---- <br />/ <br />CONTACT NAME <br />1 PHONE <br />' ;� - _ • Q/ <br />ADDRESS <br />re Ue� <br />CITY <br />/ <br />STATE <br />,,^ <br />c4lT I ZIP <br />�I <br />Owner) <br />COMPANY NAME e A /� <br />CONSULTANT PHONE <br />UAR GATE PROP 65 DATE PRIORITY <br />/r <br />STREET #if")SITE STREET / �����j2� I APN �li�� I <br />EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFRZ l• <br />Q "I ,v PHONE <br />V <br />CONTACT NAME <br />PRONE <br />I <br />ADDRESS <br />CITY <br />STATE <br />ZIP <br />CONSULTANT PHONE <br />UAR GATE PROP 65 DATE PRIORITY <br />/r <br />STREET #if")SITE STREET / �����j2� I APN �li�� I <br />EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFRZ l• <br />