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PHS/SAN JOAf -N COUNTY - ENVIRONMENTAL ALTH DIVISION <br /> COITTAMINATED SITE MFR - INPUT FORM <br /> UPDATE /^t BY REVIEWED BY DATE ENTERED <br /> ADDITION: EDIT: <br /> SWEEP'S # � COMPUTER # E DIST # LOC CODE <br /> "9 CL - nte:33 3::U <br /> - <br /> UST FILE H W FILE LAND USE FILE PWS FILE PILOT FROG <br /> FAILED PT / / SOIL CONT / 6 / (J GW CONT / / DW CONT <br /> PETROLEUM . Y / ENTERED PILOT / / F'kOG/ELEMENT ^ <br /> SITE NAME + <br /> ADDRESS <br /> PHONE <br /> -75 -3'7'7 <br /> CITY STATE CA ZIP <br /> PYyI Sia `7 <br /> CONTACT NAME CROSS STREET r <br /> PROPERTY OWNER <br /> NAME �� -rN PHONE '� <br /> i/ub ; r��i IX Lyl 4 ���� o 1/175-2­3770 <br /> MAILING/STREET ADDRES <br /> 8633 <br /> CITY c/PP STATE ZIP' ��Z <br /> CONTACT NAME PHONE G✓II/avn .A 'e) - 5" - O <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY <br /> �ak'e nrr STATE <br /> CONSULTANT PHONE <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # - (t�l DATE / III 11' '1 PROP 6S # v0 - �C/ DATE1 ,_ <br /> STREET # SITE STREET T <br /> >� �' � PRIORITY <br /> EH 23 070 (7/89) 89-19 (IV) 7/89 CNTMFR <br />