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PHS/SAN JOAQU•IN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE /"L'7/ BY REVIEWED BY --)-y� DATE ENTERED V/ /21 BY <br /> ADDITION : _____ EDIT:______ <br /> SWEEPS # qlq6 COMPUTER # DIST # IOC C DE <br /> UGT FILE H W FILEIX LAND USE FILE PWS FILE PILOT P110G <br /> FAILED PT / / SOIL CONT / / GW CONT / 'zO/ (J DW ON <br /> PETROLEUM Y / 0 1 ENTERED PILOT / / PROG/ELEMENT Z Z G <br /> SITE NAME ` Lie 5 H,40 <br /> ADDRESS (O d� 6.9 7- ,� Ujr(S PHONE <br /> CITY STATE CA ZIP <br /> CONTACT NAME V f �� S CROSS STREET q� <br /> PROPERTY OWNER <br /> NAME / e Li l S 1 PHONE <br /> MAILING/STREET ADDRESS <br /> CITY L44ro STATE CC ZIP <br /> CONTACT NAME PHONE <br /> RESPONSIBLE PARTY ( If different from Property Owner ) - <br /> COMPANY NAME S C<f r -e U }— 11 <br /> PHONE L <br /> CONTACT NAME ( oCIz,, PHONE <br /> ADDRESS <br /> CITY ,CG f�io STATE ZIP S 3�_'SmU <br /> CONSULTANT S PHONE ]-� 7 7Z <br /> SJ/EH CONTACT ��- <br /> RWQCB CONTACT OV r Q/ <br /> DHS CONTACT 17C QJUll/L <br /> OTHER CONTACT <br /> UAR # - DATE / / PROP 65 # - DATE <br /> STREET # SITE STREET s PRIORI Y <br /> EH 23 070 ( 7/89 ) 89-19 ( IV) 7/89 CNTMFR <br />