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PHS/ <br /> �: <br /> '" JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISI <br /> ONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: /�J / L n/Gj'L. BY: RX REVIEWED BY: DATE ENTERED: `a <br /> SWEEPS/SITE CODE 9',QQ, PROGRAM/ELEMENT 20(05 COMP # LOC CODE ' DIST # <br /> UGT FILE ✓ LOP FILE ✓ H W FILE SITE MITIGATION PWS FILE PRIV WELL FILE ENV ASSESS <br /> SOLID WASTE H2O O FILE EPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT IQ SJ/EH CONTACT Ktt LL DHS CONTACT <br /> OTHER CONTACT RWOCB CONTACT WOR issued Y /� NPDES issued Y /n <br /> FAILED PT / / SOIL CONT / / GW CONT / / DW CONT PETROLEUM Y <br /> XS 94 #5 <br /> L-� <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 X30'3 <br /> CITY ( CJ STATE 2IP <br /> CONTACT NAME l�J'I PHONE L <br /> /:J GCJ <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAMEJ.2.(/� .Qhs PHONE L))'Z,'I <br /> ADDRESS <br /> '74D <br /> OD/; � 54ult- 'ILI <br /> CITY l� - /!/ STATE (),,t. 2IP <br /> RESPONSIBLE PARTY (If different from Property Ouner) <br /> COMPANY NAME n PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> UAR # DATE PROP 65 # DATE V PRIORITY <br /> STREET # x-303 SITE STREET �/n w . APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br />