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PHS/z,— JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISi-m <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / I PA BY: REVIEWED BY: DATE ENTERED: / / BY: <br /> SWEEPS/SITE CODE ���� � �� PROGRAM/ELEMENT COMP # LOC CODE �I DIST # <br /> UGT FILE N LOP FILE H W FILE SITE MITIGATION r- PWS FILE �f PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE ff H2O 0 FILE EPI FILE N LAND USE FILE N OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT K DHS CONTACT <br /> OTHER CONTACT RWOCB CONTACT WDR issued Y / N NPDES issued Y / N <br /> FAILED PT / / SOIL CONT / / GW CONT / / DW CDNT PETROLEUM Y / N <br /> SUBSTANCE #1 #2 #3 #4 #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 /> ADDRESS <br /> CITY STATE ZIP <br /> CONTACT NAME PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT <br /> I <br /> PHONE <br /> UAR # DATE PROP 65 # DATE I <br /> PRIORITY <br /> STREET # SITE STREET FAPN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(1V) CNTMFR2 <br />