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PHS/ JCAOUIN COUNTY - ENVIRONMENTAL HEALTH DIVI` <br /> .:CNTAMINATED SITE D-Base MFR INPUT FORM <br /> UPDATE: 3 / Z / / Z BY: ���� REVIEWED BY: DATE ENTERED: / / BY: ) <br /> SWEEPS/SITE COOE /�� PROGRAM/ELEMENT Z- / !,'G COMP # LOC CODE ' DIST # 32-Z <br /> UGT FILE LOP FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS ✓ <br /> SOLID WASTE H2O 0 FILE EPI FILE LAND USE FILE OTHER AGENCY REPCRT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT � j � SJ/EH CONTACT �/II�(.�iuV/Y DHS CONTACT <br /> OTHER CONTACT / RWOCB CONTACT WDR issued Y / N NPOES issued Y / N <br /> FAILED PT / / SOIL CONT / / GW CONT / / DW CONT PETROLEUM Y / N <br /> SUBSTANCE #1 #2 #3 T44 <br /> #5 <br /> PRICR FAILED PT NO ACTION ✓ CLEAN UP COMPLETE DATE 3 / 2- 1 2 ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME Z v <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONTACT NAME �E t� PHONE <br /> `//� � `r�6 Z- d o 0 <br /> PRCPERTY OWNER <br /> COMPANY NAME L C V�( �. PHONE <br /> CONTACT NAME G0Al 6;e- N PHONE y/� �d// /4d <br /> ADDRESS loe�Q 36y- --2,Q 5 75 ` <br /> CITY Ste_ STATE CA ZIP S O <br /> RESPCNSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT BSS PHONE <br /> UAR # DATE PROP 65 # DATE PRIORITY <br /> STREET # 153 SITE STREET �iL �iN.�L APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />