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0 <br /> GHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE /V/ Z/gU BY GL REVIEWED BY ", DATE ENTERED /Q/�J5/,/,,) BY f <br /> / J <br /> ADDITION:— EDIT::— <br /> SWEEPS <br /> DIT::__SWEEPS # �oZZ COMPUTER # DIST # 3� i' LOC CODE I C>3 <br /> UGT FILE H W FILE LAND USE FILE F'WS FILE PILOT FROG <br /> FAILED PT / / SOIL CONT S/)7 /Sg GW CONT t /3� /aO,� DW CONT <br /> PETROLEUM N ENTERED PILOT / / PROG/ELEMENT <br /> SITE NAME , e r�jlM Q �ro I eS <br /> ADDRESS 1J c/\ �z PHONE <br /> CITYII STATE CA ZIP S 3 76 <br /> CONTACT NAME 4e S Vag CROSS STREET <br /> rA <br /> PROPERTY OWNER d II <br /> NAME i'arv�C� P(b e(ti eS nc PHONE y� S 83� 992)3 <br /> MAILING/STREET ADDRESS yj <br /> CITY S4� ����� STATE C�, ZIF' jys 83 <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 ZIF' <br /> CONSULTANT Geo l c G Tc �n, c PHONE Z�S s 3g -IMUS <br /> 6/EH CONTACT }1; <br /> RWQCB CONTACT <br /> Or O/1. B <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # - DATE / / PROP 65 # - DATE <br /> STREET # 7© ! SITE STREET KI PRIORITY <br /> EH 23 070 (7/89) 89-19 ( IV) 7/89 CNTMFR <br />