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PHS, JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVI <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: 12, / 3 /gy BY: �Iil( ' REVIEWED BY: DATE ENTERED: / / BY <br /> SWEEPS/SITE CODE �� PROGRAM/ELEMENT O COMP # LOC CODE Q3 DIST # 3L C,I <br /> UGT FILE LOP FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE_L JEPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT G''(�ie�4 G/3 SJ/EH CONTACT I-#)r:it"4 DHS CONTACT <br /> OTHER CONTACT RWOC8 CONTACT WDR issued Y / N NPDES issued Y / N <br /> FAILED PT / / SOIL CONT / / GW CONT �D/ 6 / 9/ DW CONT PETROLEUM Y / N <br /> SUBSTANCE +PT <br /> -7D(o�� #2 93 #4 #5 <br /> PRIOR FAILENO ACTION CLEAN UP COMPLETE DATE / / ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 4 5 6 DATE ACTION TAKEN: <br /> SITE NAME s. C ✓/UG �f�.�/ ��` q �0 <br /> ADDRESS /Z�� KJ�' <br /> or <br /> CITY STATE ZIP 7 <br /> CONTACT NAME PHONE l ./ <br /> PROPERTY OWNER <br /> COMPANY NAME v S• s PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS 200 3 S• C �� <br /> CITY vp STATE CQ 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 PHONE <br /> UAR # DATE PROP 65 # � 3 DATE• /Q���iq� PRIORITY <br /> STREET # /�00 SITE STREET APN # SQ-0210 / <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CHTMFR2 <br />