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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE p /11 /701 <br /> 1 /20 BY r REVIEWED BY DATE ENTERED / / BY <br /> ADDITION: EDIT: <br /> ___— <br /> SWEEPS # COMPUTER # f�".4,7/ DIST # 51 LOC CODE <br /> UGT FILE H W FILE LAND USE FILE PWS FILE PILOT 1='RCG I <br /> FAILED PT [� / 6 /9� SOIL CONT / / GW CONT / / DW CONT <br /> PETROLEUM Y / N ENTERED PILOT / / FROG/ELEMENT <br /> SITE NAME s <br /> ADDRESS �9 PHONE <br /> CITY A 14, N eCC STATE CA ZIP 47-3✓6 <br /> CONTACT NAME CROSS STREET <br /> PROPERTY OWNER <br /> NAME f' FHONE <br /> MAILING/STREET ADDRESS <br /> p (), -s <br /> CITY STATE ZIP <br /> CONTACT NAME r ,, i ANN � 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 777 PHONE <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # - DATE �� /o /'70 PROP 65 DATE <br /> STREET $ SITE STREET /� rn PRIORITY <br /> e <br /> EH 23 070 (7/89) B9-19 (•) 7/B9 CNTMFR <br />