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• PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION r t <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE / M)/101 BY EI` I REVIEWED BY -/t?? DATE ENTERED <br /> ADDITION:_ ___ EDIT :______ <br /> SWEEPS # COMPUTER # DIST # -3 a 5 LOC CODE <br /> UGT FILE H W FILE LAND USE FILE PWS FILE PILOT PROG <br /> FAILED PT / / SOIL CONT /J() GW CONT (�r- / / 9j DW CONT <br /> PETROLEUM / N I ENTERED PILOT I PROG/ELEMENT - Zz t/ <br /> SITE NAME S • fh4 4 Y- l ro L)CA5 &Sts-y07G <br /> ADDRESS a Sv G . L.p ✓� PHONE <br /> CITY �G .r, NSU STATE CA ZIP <br /> CONTACT NAME � }-L �I CROSS STREET ' r[ <br /> PROPERTY OWNER <br /> NAME Xe, jr- ) T�n <br /> ocluA5 PHONE <br /> MAILING/STREET ADDRESS a .C�V �'• �� �ro <br /> CITY �C, + �vc STATE ZIP <br /> CONTACT NAME C- 14-c�� �( PHONE <br /> RESPONSIBLE PARTY ( If different from Property Owner ) <br /> COMPANY NAME C,vVLC as dCJfIG( PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT Auq CctCUA Off, -4 PHONE E6 638 `ISS- <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # - DATE / / PROP 65 # - DATE <br /> STREET # �a, SU SITE STREET PRIORITY <br /> EH 23 070 ( 7/89 ) 89-19 ( IV) 7/89 CNTMFR <br />