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PHS/SAN JOAQUIN COUNTY — ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR — INPUT FORM <br /> UPDATE / / BY y;(!., REVIEWED BY DATE ENTEREDt� BY <br /> 8^ <br /> ADDITION: EDIT : <br /> SWEEPS COMPUTER # &#,f,35 DIST # LUC CODE <br /> UST FILE H W FILE ) LAND USE FILE PWS FILE PILOT PROS <br /> FAILED PT / / SOIL CONTI / CONT / / DW CONT <br /> PETROLEUM LY)/ N ENTERED PILOT / / FROG/ELEMENT <br /> SITE NAME <br /> ADDRESS <br /> ,34, <br /> 615— PHON L� <br /> 7 --CJc- / /(p <br /> CITY V' ?661 STATE CA ZIP <br /> CONTACT NAME �. CROSS STREET <br /> PROPERTY OWNER <br /> NAME /r " PHONEOO 9 j/�� VI <br /> MAILING/STREET ADDRESS 1 O, <br /> CITY �� ✓ STATE ZIP c�cSoZd� <br /> CONTACT NAME PHONE <br /> RESPONSIBLE PARTY ( If c9 ffe t rom Property Owner) !O <br /> COMPANY NAME /�Zc/Y( CZi 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 # _ —IA y I DATE �� / / / PROP 65 # —��3 DATE IA / l� /� <br /> STREET # ' S SITE STREET ! � PRIORITY / <br /> i <br /> EW 23 070 (7/89) 89-19 ( IV) 7/89 CNTMFR <br />