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PHS/SAN—JOACUIN COUNTY - ENVIRONMENTAL HEALTH DIVISU� <br /> CONTANIHATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: ( /p7 BY: .REVIEWED BY: DATE ENTERED: / /( / �OC BY: <br /> SWEEPS/SITE CODE l D�J� DROGRAM/ELEMENT �'!�S'U COMP.# LOC CODE DIST # �� t <br /> UGT FILE LOP FILE H W FILE SITE MITIGATILE 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 S/� �/Y S�`! SJ/EN CONTACT DHS CONTACT <br /> OTHER CONTACT G RWOCB CONTACT ' �[ WDR issued Y / N NPOES issued Y / N <br /> FAILED PT / / SOIL CONT GW CONT ( / OV CONT PETROLEUM Y / N <br /> SUBSTANCE #1 #2 #3 /, ({/� #4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN lID COMPLETE DATE 2 //Cl / 9v ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME J � <br /> ADDRESS <br /> CITY STATE ��L` ZIP <br /> CONTACT NAME PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME R'�"�I , PHONE <br /> CONTACT NAME q� / Lf,/. �.—/ ay-,� PHONE <br /> ADDRESS <br /> CITY �by`, d7` STATE ZIPg)! l� '+j� 2-3 g/ <br /> J� r <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS 1 <br /> CITY STATE ZIP <br /> CONSULTANT _ ' / . /` / a y/�,,, PHONE 7 - G.-, `I <br /> UAR # DATE a N;o `PROP 65 /#c'- ` DATE ! PRIORITY <br /> AJ <br /> STREET # SITE STREET APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 (/'� <br />