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r� <br /> k, <br /> PH5/SAN "QUIN COUNTY - ENVIRONMENTAL HEALTH DIVI <br /> Side B - LOP PROGRAM - MFR INPUT FORM <br /> UPDS ATE, BY I W' L SITE CODE qo I, (o ADDRESS 1 f <br /> 4 <br /> Primary / Additional RESPONSIBLE PARTY ,q,4� <br /> COMPANY NAME J� ��r�GL j PHONE <br /> J CONTACT NAME {S L ►1 O PHONE C2 , 23 <br /> ADDRESS �L1�Off[ <br /> CITY �� - STATECA� 21P <br /> V -----,P.rimary / Additional RESPOIISIBLE PARTY <br /> COMPANY NAME `� Ff PHONE' ' <br /> CONTACT NAME y PHONE ' <br /> ADDRESS 4' <br /> CITY STATE ZIP <br /> Primary / Additional RESPONSIBLE PARTY <br /> COMPANY NAME % <br /> .f PHONE 4_1 <br /> CONYACT NAME PHONE <br /> ADDRESS r3 <br /> CITY STATE ZIP <br /> CONTAMINATED SITE MFR - Addition: Edit: <br /> UGT FILE FAILED PT / / SOIL CONT % / Olt CONT / / DW CONT Y / H <br /> PROPERTY OWNER <br /> COMPANY NAME PHONE <br /> CONTACT NAME ��S Cl 4 ��I1G�S PHONE LULU`l �j 23 <br /> ADDRESS ivl Z� Oc�CI 7G� G <br /> CITY VL` STATE ZIP L�3 � <br /> COHSGLTANI;r, VvQ� y\UY`1 <br /> RWaC6 CONTACT-7� ��Y1 UAR J DATE: <br /> (� PROP 65 0 CID O-Zo DATE:_/JFJ-1Q <br /> QHS CONTACT <br /> WDR issued: Y / N NPDES issued: Y / N <br /> STREET # G�� SITE STREET c wt s��l T. APH N j <br /> PILMFB revised 5/91 <br /> 0 <br />