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r <br /> PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE �� /�o/ Qj BY REVIEWED BY DATE ENTERED BY <br /> ADDITION: EDIT: <br /> SWEEPS # COMPUTER # DIST # -Z,j / LOC COD <br /> v3 <br /> UGT FILE H W FILE LAND USE FILE PWS FILE PILOT PROS <br /> FAILED PT SOIL CONT / / GW CONT 1 /0 / 3� / DW CONT <br /> PETROLEUM Y / N ENTERED PILOT / / PROS/ELEMENT 2 0 <br /> SITE NAME <br /> i�s <br /> ADDRESS / PHONE c <br /> CITY /iGc STATE CA ZIP `/S37G <br /> CONTACT NAME gym` CROSS STREET <br /> PROPERTY OWNER <br /> NAMEPHONE �/S <br /> MAILING/STREET ADDRESS <br /> CITY STATE ZIF' <br /> � G � <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 CIO 4� `j S �hG PHONE S38 7Fft <br /> SJ/EH CONTACT 2�ci//�✓ <br /> RWQCB CONTACT �- 1 <br /> M C�/rd <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # - DATE / / PROP 65 # - /'/ DATE <br /> STREET # X c, SITE STREET 11�� PRIORII/TY <br />