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PHS/SAh AOUIN COUNTY - ENVIRONMENTAL HEALTH DIViSIO,. <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / / BY: REVIEWED BY: DATE ENTERED: d- /2 BY: <br /> SWEEPS/SITE CODE PROGRAM/ELEMENT b COMP # 23 jq--22'�5 T LOC CODE DIST # <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILELAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT SJ/EH CONTACT DHS CONTACT <br /> OTHER CONTACT RWOCB CONTACT WDR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT , 2 /� GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE L-2-U'375 #3 F#4 #5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> EIIFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME D,v04'7 <br /> ADDRESS <br /> S. <br /> CITY STATE eA ZIP q,5-33 rZ <br /> CONTACT NAME O F PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE / L <br /> CONTACT NAME PHONE <br /> ADDRESS ' L <br /> CITY STATE P _ ZIP QS a 3 r7 <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> v <br /> UAR # �' DATE �� PROP 65 # DATE / Q./ PRIORITY <br /> <_- 1� ✓ <br /> 14 <br /> STREET # t Ll SITE STREET �? APN # <br /> I �• <br /> EH 23 070 (7/89) 89-19(IV) CNTMFR2 REVISED 1294 <br />