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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br />CONTAMINATED SITE MFR - INPUT FORM A 4 <br />UPDATE I /C /, BY REVIEWED BY DATE ENTERED // /�i/��i NY <br />ADDITION: __ EDIT:-, — I <br />SWEEPS N <br />lq)&2 <br />/ <br />COMPUTER # <br />) l j �U <br />DIST <br /># <br />DW CONT <br />STATE <br />LOC <br />CODE <br />N <br />UGT FILE <br />H <br />W FILE <br />LAND <br />USE FILE <br />I ) Z� <br />a1/ <br />PWS <br />FILE <br />PILOT <br />PROS <br />FAILED PT <br />/ <br />/ <br />SOIL CONT <br />/(� / <br />GW CUNT <br />/ / <br />DW CONT <br />STATE <br />PETROLEUM <br />Y / <br />N <br />ENTERED PILOT <br />PROG/ELEMENT <br />PRIORITY <br />SITE NAME < P jl <br />ADDRESS PHONE <br />CITY STATE CA ZIP <br />CONTACT NAME Vl CROSS STREET <br />PROPERTY OWNER <br />NAME <br />I il&l71 <br />PHONE <br />/ /�/ <br />(J <br />MAILING/STREET ADDRESS <br />()o <br />CITY <br />�- �, <br />STATE <br />Ct-} <br />ZIF' <br />SITE STREET <br />STATE <br />v <br />ZIF' <br />PRIORITY <br />CONTACT NAME <br />I ) Z� <br />a1/ <br />PHONE <br />RESPONSIBLE PARTY (If different from Property Owner) <br />COMPANY NAME <br />- <br />PHONE <br />/ /�/ <br />(J <br />CONTACT NAME <br />J <br />PHONE <br />DATE <br />ADDRESS <br />STREET q <br />CITY <br />SITE STREET <br />STATE <br />ZIF' <br />PRIORITY <br />CONSULTANT <br />- <br />PHONE <br />/ /�/ <br />(J <br />SJ/EH CONTACT <br />8 <br />RWQCB CONTACT <br />DATE <br />DHS CONTACT <br />STREET q <br />OTHER CONTACT <br />SITE STREET <br />UAR # <br />- <br />DATE <br />/ /�/ <br />(J <br />PROP 65 <br />8 <br />- <br />DATE <br />STREET q <br />SITE STREET <br />PRIORITY <br />EH 23 070 (7/89) 89-19(IV)7/89 CNTMFR <br />