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■ \. <br />1' <br />PHS/SAN JUIN COUNTY — ENVIRONMENTASHEALTH DIVISION <br />,JNTAMINATED SITE MFR — INPUT FORM <br />UPDATE I9/ / A76, BY". REVIEWED BY DATE ENTERED J� /�7 /�j� BY 1 10 <br />AdDITION: EDIT: <br />SWEEPS # <br />/ �� <br />COMPUTER it <br />/j1M)j %-7-7 <br />DIST # <br />?�` <br />LOC CODE <br />g/ <br />UGT FILE <br />ENTERED PILOT <br />H W FILE <br />FROG/ELEMENT <br />LAND USE FILE <br />PHONE <br />PWS FILE <br />l) <br />r'ILOT FROG <br />CROSS STREET�����/��/ <br />Z� <br />FAILED PT <br />/ / <br />SOIL CONT <br />/!)/ /i� <br />GW CONT <br />/ / <br />DW COIVT <br />PETROLEUM <br />/ N <br />ENTERED PILOT <br />/ / <br />FROG/ELEMENT <br />PHONE <br />CONTACT NAME <br />l) <br />CROSS STREET�����/��/ <br />Z� <br />SITE NAME <br />nn <br />F'HOPJE <br />ADDRESS <br />1V S <br />p� S� S <br />PHONE <br />CITY <br />S <br />ZIF' <br />STATE <br />CAZIP <br />PHONE <br />CONTACT NAME <br />l) <br />CROSS STREET�����/��/ <br />PROPERTY OWNER <br />NAME <br />�� <br />F'HOPJE <br />I <br />MAILING/STREET ADDRESS <br />/ / <br />CITY <br />PROP 65# <br />STATE <br />DATE <br />ZIF' <br />STREET # <br />CONTACT NAME <br />PHONE <br />STREETJig--�i560 <br />RESPONSIBLE PARTY (If different from Property Owner) <br />COMPANY NAME <br />- /tet 5 <br />PHONE <br />I <br />CONTACT NAME <br />/ / <br />PHONE <br />PROP 65# <br />ADDRESS <br />DATE <br />CITY <br />STREET # <br />STATE <br />ZIP <br />STREETJig--�i560 <br />CONSULTANT <br />'• <br />PHONE <br />DATE <br />SJ/EH CONTACT <br />/ / <br />RWOCB CONTACT <br />PROP 65# <br />DHS CONTACT <br />DATE <br />OTHER CONTACT <br />STREET # <br />UAR # <br />'• <br />— <br />DATE <br />/ / <br />PROP 65# <br />DATE <br />/Gy <br />STREET # <br />ry <br />SITE <br />STREETJig--�i560 <br />N / <br />PRIORITY <br />EH 23 070 (7/89) 89-19(IV)7/89 CNTMFR <br />