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PHS/' IOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVIS <br /> ,ONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: /� /�C / / BY: REVIEWED BY: DATE ENTERED: 712 / C,/ BY: <br /> SWEEPS/SITE CODE ��� PROGRAM/ELEMENT /1 COMP # LOC CODEI c 7 <br /> DIST <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O Q FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNITSJ/EH CONTACT ��T L FF DHS CONTACT A/e�/, ) I <br /> OTHER CONTACT RWQCB CONTACT WOR issued Y / N\ NPDES issued Y / O <br /> FAILED PT SOIL CONT GW CONT j OW CONT PETROLEUM 0 <br /> SUBSTANCE #1 /„ / ( #2 �D 93 #3 #4 #5 <br /> PRIOR FAILED PT w NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATES ACTION TAKEN: <br /> SITE NAMENCOv/ . 1 <br /> ADDRESS //-/ �V <br /> CITY Aj STATE ZIP 9 <br /> CONTACT NAME /� 1,(J fJVQ/VI /\ PHONE <br /> PROPERTY OWNER `[ <br /> COMPANY NAME PHONE <br /> CONTACT NAME �i �G E A. X�, r`C PHONE <br /> ADDRESS (�./� /6' Llolt Ile 4/ <br /> CITY U sQ2 STATE (� ZIP <br /> RESPONSIBLE PARTY (if different from Property Owner) < `+ <br /> COMPANY NAME f _- &�� PHONE <br /> CONTACT NAME PHONE Q. <br /> ADDRESS /Q/ Cc TL=A �A-c aE / <br /> CITY Ls�<.. STATE /' ZIP <br /> CONSULTANT 6:a*. SOS PHONE 4 <br /> UAR # DATE PROP 65 # (�'_l 7 DATE �, �' PRIORITY <br /> STREET # / SITE STREET /�� 1 7APN # !�p 3• OTiD 2� <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />