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GHS/SAN JM 'IN COUNTY — ENVIRONMENTAL EALTH DIVISION <br /> L±rdTAMINATED SITE MFR — INPUT'FORM <br /> BY �! '; REVIEWED BY <br /> DATE ENTERED /.lJ BY / <br /> ADDITION: EDIT: <br /> SWEEPS # , i; � COMPUTER # 7 <br /> a y6�dz/ DIST # LOC CODE <br /> UGT FILE <br /> H W FILE LAND USE FILE PWS FILE ;. <br /> ILOT I�kCG <br /> FAILED PT SOIL CONT / � / � GW CONT / / DW CONT <br /> PETROLEUM `Y; N ENTERED PILOT / <br /> / PROG/ELEMENT <br /> SITE NAME <br /> ADDRESS <br /> PHONE <br /> CITY —Wo / � STATE CA ZIP, p <br /> CONTACT NAME �A G / v <br /> C'QTi CROSS STREET <br /> PROPERTY OWNER <br /> NAME <br /> PHONE <br /> MAILING/STREET ADDRESS <br /> CITY <br /> STATE ZIP, <br /> CONTACT NAME <br /> 'HONE <br /> RESPONSIBLE PARTY ( If different from Property Owner) <br /> COMPANY NAME <br /> PHONE <br /> CONTACT NAME <br /> PHONE <br /> ADDRESS <br /> CITY <br /> STATE ZIF <br /> CONSULTANT <br /> PHONE <br /> SJ/EH CONTACT <br /> RWOCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # �( C� 6 . DATE �� /, / /v PROP 65 # <br /> STREET SITE STREET ��� _ PRIORITY <br /> EH 23 070 (7/89) 89-19 ( IV) 7/89 CNTMFR T J <br />