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PHS/SAN JOAAN COUNTY — ENVIRONMENTAL41ALTH DIVISION <br /> CONTAMINATED SITE MFR — INPUT FORM <br /> UPDATE � / BY lcv <br /> REVIEWED BY DATA: ENTERED / / BY <br /> taw- 3y-3,-- 38 39 y�'/� y7 DDITION: _ EDIT:.._ <br /> WEEPS # COMPUTER # R DIST # 132,5.— LOC CGDE <br /> -•- • UGT FILE H W FILE LAND USE FILE LIPWS FILE V" � OT PROD 7 <br /> FAILED PT / / SOIL CONT 3 /1 1 ,.901 GW CONT / / DW CUNT <br /> PETROLEUMY / N ENTERED PILOT / / FROG/ELEMENT <br /> SITE NAME T <br /> ADDRESS PHONE <br /> 24�=CIT- <br /> STATE CA ZIP <br /> 9.533, � <br /> CONTACT NAMEJ � M CROSS STREET _ <br /> PROPERTY OWNER <br /> NAME PHOrJE <br /> S <br /> MAILING/STREET ADDRESS <br /> CITY STATE ZIP <br /> CONTACT NAME PHONE <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAMEPHONE <br /> I <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE Z IF° <br /> CONSULTANT PHONE <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # - DATE / / PROP 65 # - DATE <br /> STREET # - SITE STREET !�Q PRIORITY <br /> EH 23 070 (7/89) 89-19 (IV) 7/89 CNTMFR <br />