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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE �/ /J/ /l�� JBYJ REVIEWED BY _ r ATE ENTE RED J /, ; /� ; BY <br /> ADDITION:,Y EDIT- <br /> SWEEPS # �> COMPUTER # �� GL �1U DIST # 3 ` LOC CODE 02- <br /> UGT FILE H W FILE LAND USE FILE PWS FILE PILOT PROG /( <br /> FAILED PT / / SOIL CONT j /,,-7 GW CONT -7 /tZ /2 S DW CONT <br /> PETROLEUM / N ENTERED PILOT y / / �G' PROG/ELEMENT <br /> SITE NAME _z <br /> ADDRESS GAG' / �� PHONE Zo5 ) <br /> CITY �` STATE CA ZIP S z cw <br /> CONTACT NAME s �f� CROSS STREET <br /> PROPERTY OWNER <br /> NAME J t r�MC-r ��1 L PHONELo ) 5/�z_ 029 <br /> MAILING/STREET ADDRESS &X Y G 6 <br /> CITY v STATE ZIF' q3e-527_ 0Y <br /> CONTACT NAME em1 f O4 PHONE 2Vj) 5 aZ_ C2L,I <br /> RESPONSIBLE PARTY ( If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT O T blv✓� <br /> FPHONEfi/S) �62-777 -7— <br /> SJ/EH <br /> CONTACT er,rio( <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT c / - CC' <br /> UAR # - DATE / / PROP 65 # - DATE <br /> STREET SITE STREET PRIORITY <br /> EH 23 070 (7//89) 89-19 ( IV) 7/89 CNTMFR <br />