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, <br /> RHS/SAN JOIPMUIN COUNTY - ENVIRONMENTAC'HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE /24/520 <br /> / BY I KE REVIEWED BY DATE ENTERED / / BY <br /> ADDITION:_� EDIT• <br /> SWEEPS # 2 Z COMPUTER # 67�Z� DIST # 3Z� ; LOC CODE <br /> UGT FILE H W FILE LAND USE FILE PWS FILE PILOT PROS <br /> FAILED PT / / SOIL CONT c;i / / GW CONT / / DW CONT <br /> PETROLEUM Y / N ENTERED PILOT / / FROG/ELEMENT <br /> SITE NAME N b N <br /> ADDRESS2 3 � C -FL_CC O PHONE 2 � <br /> CITY LIh17� 11 STATE CA ZIP �5z <br /> CONTACT NAME ��� CROSS STREET IN <br /> PROPERTY OWNER <br /> NAME � PHONE CZ�1 S`S� <br /> MAILING/STREET ADDRESS - .O <br /> 4+19 <br /> CITY LII/ CTl STATE C�- ZIP <br /> CONTACT NAME PHONE � � �p <br /> RESPONSIBLE PARTY (If different from Property Owner) D <br /> COMPANY NAME c PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR #J(10 7A, DATE /-2-4 /c?(7) PROP 65 # c'lC, DATE G /-yl / <br /> STREET # Z-33SITE STREET -F��� 720�� PRIORIT7Y GC <br /> EH 23 070 (7/89) 89-19 (,..,) 7/89 CNTMFR <br />