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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATq/2 la, <br /> /c6 BY REVIEWED BY DATE ENTERED / /9/ BY <br /> ADDITION: EDIT:�� <br /> SWEEPS # JJ COMPUTER # DIST # JZ/ LOC C DE QI <br /> UGT FILE / H W FILE LAND USE FILE PWS FILE PILOT PROG <br /> FAILED PT 5 /(o /qo SOIL CONT /,?l 1946W CONT / / DW CONT <br /> PETROLEUM Y )/ N ENTERED PILOT / / GROG/ELEMENT <br /> SITE NAME <br /> ADDRESS � )11 PHONE <br /> CITY ✓70CT,, STATE CA ZIP 95�� <br /> CONTACT NAME LILCCROSS STREET <br /> PROPERTY OWNER <br /> NAME el& PHONE <br /> MAILING/STREET A-D/DRESS TD _RDX 4023 <br /> CITY OY7C0/G� STATE C,4- ZIP <br /> CONTACT NAME U PHONES fS l Z375extl <br /> RESPONSIBLE PARTY ( If different from Property Owner) <br /> COMPANY NAME S PHONE <br /> CONTACT NAMEJ 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 I /Z/ /co I PROP 65 # - DATE /Z/0,, /CJO <br /> STREET # 0�)�/ SITE STREET �jJ4iL/�n PRIORITY <br /> EH 23 070 (7/89) 89-19 ( IV) 7/89 CNTMFR <br />