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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE BY DATE ENTERED Z � q BY <br /> ADDITION: EDIT: DELETE: <br /> SWEEPS # COMPUTER # DIST # LOC CODE <br /> UGT FILE H W FILE X LAND USE FILE PWS FILE PILOT PROG <br /> FAILED PT / / SOIL CONT / / IGW CONT IDW CONT <br /> PETROLEUM Y � IPILOTJT Y / (N) ENTERED PILOT <br /> SITE NAME 6re--,� <br /> ADDRESS S 3 PHONE <br /> CITY �� STATE CA ZIP •Z <br /> J <br /> CONTACT NAME CROSS STREET L✓s� �S <br /> PROPERTY OWNER <br /> NAME IfS/ — PHONE <br /> MAILING/STREET, ADDRESS 33Z w r,,�w1l" <br /> CITY �oC STATE C ZIP <br /> CONTACT NAME0„L L�� �C�� PHONE <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> CONTACT NAME PHONE <br /> COMPANY NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT / PHONE <br /> SJLHD CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT �o��✓ / ) Soh <br /> OTHER CONTACT <br /> FARj Y / (� UAR / / PROP 65 Y / / / PRIORITY <br /> SITE STREET ��j/, �, STREET # /� , <br /> EH 23 070 (5/89) 89-19 (IV) 5/89 CNTMFR <br />