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PHS/SAN JOAQUIN COUNTY — ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR — INPUT FORM <br /> UPDATE "� /!j /Cl 4 <br /> BY L- REVIEWED BY DATE ENTERED <br /> ADDITION: EDIT: <br /> SWEEPS # -2COMPUTER # �, _5;i DIST # J �y LOC CODE <br /> UST FILE H W FILE LAND USE FILE PWS FILE PILOT PROD <br /> FAILED PT / / SOIL CONT / / GW CONT / / DW CONT <br /> PETROLEUM Y / N ENTERED PILOT / / FROG/ELEMENT <br /> SITE NAME / " <br /> esk/i) ;;� C 45 <br /> ADDRESS /� PHONE <br /> CITY - / �. STATE CA ZIP <br /> CONTACT NAME i < / CROSS STREET <br /> PROPERTY OWNER <br /> NAME PHONE <br /> MAILING/STREET ADDRESS <br /> CITY STATE ZIF' <br /> CONTACT NAME PHONE <br /> RESPONSIBLE PARTY ( If different from Property Owner) <br /> COMPANY NAME 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 # — DATE / / PROP 65 # — DATE <br /> STREET # SITE STREET PRIORITY <br /> EH 23 070 (7/89) 89-19 ( IV) 7/89 CNTMFR <br />