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PHS/S�;ACUIN COUNTY - ENVIRONMENTAL HEALTH OIVISI <br /> CONTAMINATED SITE D-Base MFR - INPUT FORM / <br /> UPDATE: /19 / t. /�F. 9Y: R_'Vl E'AED BY: .(T.) DATE ENTERED: 'SIO/ ULA / 9 BY• 971, <br /> SWEEPS/SITE CODE �- PROGRAM/ECE.MENT I�, /'� Camp k LOC CODE D Z— DI T k <br /> / / b <br /> UGT FILE PILOT FILE H W FILE I SITE MITIGATION PWS 7- T I <br /> PRIV WELL FILE I ENV ASSESS <br /> SOLID WASTE H2O 0 FILE EPI FILE I LAND USE FILE OTHER AGENCY REPORT EMERGENCY RESPONSE <br /> LEAD AGNCY/UNIT ��.i SJ/EH CONTACT DHS CONTACT -- <br /> OTHER CONTACT RWQC3 =NTACT WOR issued Y / N NPDES issued Y / N <br /> FAILED PT SOIL CONT p/ tL GW CONT DW CONT ETROLEUM Y / N <br /> SUBSTANCE k1 k2 1 913 k4 q5 <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 /> CITY ©p. STATE .. ZIP <br /> CONTACT NAME +f' L, f1Dv� PHONE <br /> PROPERTY OWNER <br /> COMPANY NAME , �. /D. PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS A/DD ( J <br /> CITY l-C,'d STATE ZIP <br /> RESPONSIBLE PARTY (If different from Property C1 er) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> UAR �- U�Z DATE lU /O PROP 65 k 47 a,,/�,s DATE /U/ 4yy PRIORITY <br /> STREET k / �D SITE STREET I !� 4 APN k <br /> EH 23 070 (7/89)REVISEO 03/91 89-19(IV) CNTMFR2 V 1�„ <br />