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PHSf JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVI <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM <br /> UPDATE: / /�z BY: REVIEWED BY: DATE ENTERED: / BY: <br /> SWEEPS/SITE CODE 9/ PROGRAM/ELEMENT 2/ J� COMP # LOC CODE 9 9 DIST # 3 LO <br /> UGT FILE LOP FILE H W FILE 1 SITE MITIGATION PW5 FILE PRIVT�FILE ENV ASSESS <br /> SOLID WASTE H2O 0 FILE JEPI FILE LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT ���j�Is/ /� SJ/EH CONTACT DHS CONTACT <br /> OTHER CONTACT RWOCB CONTACT WDR issued Y / N NPDES issued Y / N <br /> Y <br /> FAILED PT / / SOIL CONT /' / GW CONT / / OW CONT PETROLEUM Y / N <br /> SUBSTANCE #1 ` #2 193 1 #4 #5 <br /> PRIOR FAILED PT <br /> (NO <br /> ACTION GLEAN UP COMPLETE DATE <br /> ENFORCEMENT ACTION Y / <br /> ENFORCEMENT TYPE: 1 2 13 4 S 6 DATE ACTION TAKEN: <br /> SITE NAME <br /> ADDRESS <br /> CITY ��F TTTiLL STATE ZIP /4t5-Z <br /> CONTACT NAME PHONE 1S V6 Z3 . <br /> PROPERTY OWNER <br /> COMPANY NAME t=� D�CJI ,I . PHONE <br /> CONTACT NAME PHONE -Vl5j .5- Z� <br /> I <br /> ADDRESS Z3, <br /> CITY STATE (-f� ZIP <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> PHONE <br /> COMPANY NAME <br /> CONTACT NAME <br /> f� PHONE <br /> y r <br /> ADDRESS " <br /> f ' <br /> CITY STATE ZIP <br /> PHONErp <br /> GJ <br /> CONSULTANT + ` <br /> I` <br /> i <br /> E <br /> UAR # DATE PROP 65 # DATE PRIORITY <br /> STREET # SITE STREET APN # <br /> EH 23 070 (7/89)REVISED 03/91 89-19(IV) CNTMFR2 <br /> a r, <br />