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GHS/SRN JL, :UIN COUNTY - ENVIRONMENTF� HEALTH DIVISION <br /> ZONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE 3/ q/ R <br /> BY EVIEWED BY DATE ENTERED / / 8Y <br /> AD ITION: EDIT: <br /> SWEEPS # paCCl117 COMPUTER # DIST # 3� LOC CODE O <br /> UGT FILE v <br /> H W FILE LAND USE FILE GWS FILE PILOT PRCG <br /> FAILED PT / / SOIL CONT ? / ? /�PP GW CONT / / DW CONT <br /> PETROLEUM Y / N I ENTERED PILOT / / PROD/ELEMENT <br /> SITE NAME let <br /> ADDRESS PHONE II <br /> CITYSh /i STATE CA ZIP <br /> CONTACT NAME eElr� C G� CROSS STREET I t;& <br /> PROPERTY OWNER <br /> NAME PHONE <br /> MAILING/STREET ADDRESS r �� G Z 0 IZ— <br /> CITY Gz�'5` S n l STATE ZIP 6 <br /> CONTACT NAME UPJ PHONE <br /> RESPONSIBLE PARTY ( If different from Property Owner) <br /> COMPANY NAME C' �S '7 l�, PHONE <br /> J _ I <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> \ <br /> [OTHER CONTACT <br /> UAR # c - ag DATE 3/i� / �G PROP 65 <br /> STREET # SITE STREET / PRIORITY <br /> EH 23 070 ('7/89) 89-19 ( IV)7/89 CNTMFR <br />