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PHS/SAI' 'AQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> .AMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: 6 /�6 /�r BY: REVIEWED BY: W DATE ENTERED: - 12— <br /> / / BY: <br /> i' <br /> SWEEPS/SITE CODE / PROGRAM/ELEMENT 1 L <br /> CCMP # LOC CODE DIS # 1 325— <br /> 1 <br /> UGT FILE PILOT FILE H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O D FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT f1�� _ �� SJ/EH CONTACT DHS CONTACT M pyaN Cc-, bf-f 49� <br /> OTHER CONTACT IJ RWQCB CONTACT �ob P�f mug ti,� WDR issued Y / d NPOES issued Y / <br /> FAILED PT SOIL CONT GW CONT OW CONT �ETROLEUM Y / 0) <br /> SUBSTANCE #1 S " #2 #3 :4 ~5 <br /> PRIOR FAILED PT NO ACTION CLEAN UP COMPLETE DATE ENFORCEMENT ACTION Y / N <br /> ENFORCEMENT TYPE: 1 2 3 /4 5 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS <br /> STATE �/� ZIP <br /> CITY � OC � � 77 <br /> CONTACT NAME /v • PHONE G/J��_ ?'7c/ j617 <br /> PROPERTY OWNER <br /> COMPANY NAME /�O PHONE �!s-_ _ /r <br /> Cs P /u P,Ve 7 <br /> j lq �L C <br /> CONTACT NAMEPHONE <br /> Al <br /> ADDRESS o� /Sy/vnJ S' O <br /> CITY STATE 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 / S j �j,F�/'d PHONE <br /> UAR # DATE PROP 65 # F9/- z GATE p� PRIORITY <br /> STREET # SITE STREET / APN # /�3—dw^�,`��,J <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 1 <br />