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PHS/SAN JOAF 'N COUNTY - ENVIRONMENTAL •ALTH DIVISION <br /> CUrfAMINATED SITE MFR - INPUT"FORM <br /> UPDATE /d d'/ BY REVIEWED BY CEJ DATE EIVTERED <br /> ADDITION• EDITe <br /> SWEEPS # Std COMPUTER # Glfjl/�CFa y DIST # LOC CODE <br /> UGT FILE H W FILE LAND USE FILE GWS FILE PILOT 1=ACG <br /> FAILED PT / / SOIL CONT '(0 / /u GW CONT / / DW CGIVT <br /> PETROLEUM u/ N ENTERED PILOT / / FROG/ELEMENT <br /> SITE NAME G ,G/r l <br /> ADDRESS <br /> �/ 1O[ej,�jul�j�/ / PHONE <br /> CITY ' `YtJ STATE CA ZIF <br /> CONTACT NAME GeuJ� i/ CROSS STREET <br /> a•c� <br /> PROPERTY OWNER <br /> NAME sz:l - PHONE <br /> MAILING/STREET ADDRESS <br /> CITY - STATE ZIF' <br /> CONTACT NAME PHONE Cog 37"�JrOO <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> I <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIF' <br /> CONSULTANT PHONE <br /> SJ/EH CONTACT <br /> RWOCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # - DATE PROP 65 # - DATE <br /> STREET # rl <br /> �� SITE STREET ' PRIOkITY <br /> EH E3 070 (7/89) 89-19 ( 7/89 CNTMFR <br /> .r .s <br />