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PHS/SAN JOAQU COUNTY - ENVIRONMENTAL HL,_,_TH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE ( /ZS /'<< BY r.-r REVIEWED BY DABY <br /> ADDITION:_,__ <br /> SWEEPS # It,> ?,6 COMPUTER # S09T,# DIST # LOC CODE O I <br /> ti <br /> UGT FILE x H W FILE LAND USE FILE PWS FILE PILOT FROG <br /> FAILED PT / / SOIL CONT /ZS /a( GW CONTI DW CONT <br /> PETROLEUM L'J/ N ENTERED PILOT / / PROD/ELEMENT 23 $L7 <br /> SITE NAME 541tr4 F M(,�.k D <br /> ADDRESS got 01Apo14D g-l'. PHONE (,?#q) 4e12_-SgO6 <br /> CITY S� STATELA ZIP Ct�� j <br /> CONTACT NAME GLARFNc,E TINES CROSS STREET <br /> PROPERTY OWNER <br /> NAME -,4 r-7.r PHONE 213) $$ - 7766 <br /> MAILING/STREET ADDRESS 44,4- r,*J Ave <br /> CITY `p5 TATE G4- ZIF' <br /> CONTACT NAME PHONE <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 /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # p - (ja� DATE 1) / /oro OP 65 # old - 236 EDEI /cep <br /> STREET #- --- y_�.__— SITE STREET / p�(� RITY <br /> ,\, EH 23 070 (7/89) 89-19 (,) 7/89 CNTMFR <br />