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-PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE j/ /8 / jBy REVIEWED BY DATE ENTERED / / / BY <br /> ADDITION: EDITd/ <br /> SWEEPS # COMPUTER 2-1 DIST # r LOC CODE <br /> UST FILE H W FILE LAND USE FILE PWS FILE ILOT FROG <br /> FAILED PT / / TSOIL CONT / / GW CONT / / DW CONT <br /> PETROLEUM Y / N I ENTERED PILOT / / F• <br /> ROG/ELEMENT �3 , �'� <br /> SITE NAME <br /> ADDRESS3 S, .� d'(` PHONE <br /> CITY C 6( {' STATE CFS ZIP <br /> CONTACT NAMEJ CROSS STREET <br /> PROPERTY OWNER <br /> NAMEJ <A <br /> PHONE <br /> MAILING/STREET ADDRESS <br /> CITY STATE ZIP, <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 ZIP <br /> CONSULTANT PHONE <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # DATE ! / PROP 65 # — DATE <br /> STREET # SITE STREET PRIORITY <br /> EH 23 070 (7/89) al-190000)7/89 CNTMFR �-. <br />