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PHS/SAN JL IUIN COUNTY - ENVIRONIIIENTi,1HEALTH DIVISION <br /> .wJNTAMINATED SITE MFR - INPUT FORM <br /> UPDATE /�Z /�� gy REVIEWED BY <br /> A�Jlja DATE ENTERED 9/ y/9c� BY <br /> ADDITION: EDIT: / <br /> SWEEPS # COMPUTER # <br /> �l 5E-1- Oa2- DIST <br /> - UGT FILE H W FILE LAND USE FILE . / -� <br /> FWS FILE FILGT 1=kOG v <br /> FAILED PT / / SOIL CONT <br /> /s / � GW CONT / / OW CONT <br /> PETROLEUM Y / N ENTERED PILOT <br /> SITE NAME <br /> ADDRESS g <br /> C iJ PHONE <br /> clry ^IsZ <br /> STATE CA ZIF� <br /> CONTACT NAME <br /> {yj CROSS STREET <br /> PROPERTY OWNER <br /> NAME <br /> F'HONE 1 <br /> MAILING/STREET ADDRESS <br /> CITY ftR <br /> 70 STATE ZIP <br /> CONTACT NAME7 X520 <br /> PHONE <br /> RESPONSIBLE PARTY ( If different from Property Owner) , 2/., � <br /> COMPANY NAME <br /> CONTACT NAME PHONE I <br /> ADDRESS PHONE <br /> CITY <br /> STATE ZIP <br /> CONSULTANT <br /> • PHONE <br /> SJ/EH CONTACT <br /> RWOCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # �, - (F DATE PROP 65 # , - <br /> STREET # Cr, DATEz / <br /> a� SITE STREET <br /> PRIORITYEH 23 070 (7/89) 89-19 (IV) 7/89 CNTMFR <br />