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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE / / [BYj REVIEWED BY DATE ENTERED <br /> ADDITION: EDIT: <br /> SWEEPS # /��� COMPUTER # i110Ce DIST # LOC CODE <br /> UGT FILE W FILE LAND USE FILE PWS FILE PILOT PROG <br /> FAILED PT / / SOIL CONT GW CONT / / DW CONT <br /> PETROLEUM iY / N ENTERED PILOT / / PROG/ELEMENT <br /> SITE NAME <br /> ADDRESS ry�A�n' PHONE <br /> CITY STATE CA ZIP <br /> CONTACT NAMEE Q <br /> CROSS STREET � �,4- <br /> PROPERTY OWNER <br /> NAMEJ �� l �cr�r-� F HONE C.209j 7 <br /> MAILING/STREET ADDRESS _ "R P o- 9as <br /> �/os� % o�tG,ooh gS a <br /> CITY � l� STATE <br /> CONTACT NAMEJ � � PHONE <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME S.� PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT PHONE <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # - DATE /G /02 S/ �: PROP 65 # - DATE <br /> STREET # _��� SITE STREET �;ir, PRIORITY <br /> EH 23 070 (7/89) 89-19 ( IV) 7/89 CNTMFR <br />