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/# <br />STREET i I <br />(PROP 65 I Y <br />9 <br />I <br />IJAR Y / SDIUAR <br />SITE STREET <br />EH 21 o'n IRIon% <br />!PRIORITY j / / <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />CONTAMINATED SITE MFR - INPUT FORM <br />0/ IBY I a 1DATE ENTERED <br />ADDITION: EDIT: DELETE: <br />UPDATE 8c1 I B Y 1 <br />SWEEPS <br />MPUTER <br />UGT FILE 'FILE 1H W I y (LAND USE FILE 1 IPWS FILE <br />DIST # I -2 'LOC CODE 1 Cc- / / <br />(PILOT PROG I <br />FAILED PT / / SOIL CONT <br />PETROLEUM PILOT Y /CO <br />6 / /V 1GW CONT k6/ y /y IDW CONT I <br />2 c/5 ENTERED PILOT I / <br />PROPERTY OWNER <br />CONTACT NAME I <br />ADDRESS I (00/ <br />CITY I <br />SITE NAME 51..11.6,/ Poic Rim A _ <br />/4, <br />I (CROSS STREET <br />:TATE 1 CA ZIP I -- 3q <br />PHONE <br />4/1,7 <br />kiti 4)1 r ro <br />RESPONSIBLE PARTY (If <br />CONTACT NAME I <br />(oey ) <br />MAILING/STREET ADDRESS <br />C I T-Y-1' <br />NAME I <br />different from Property Owner) <br />s <br />STATE <br />(PHONE (ç ) (A .1q) I 1 _ I/20s_ <br />/A' ,,702? <br />PHONE <br />ce, ZIP <br />(Ks) '-/q/ - '120 k <br />9(03 (D <br />CONTACT NAME <br />COMPANY NAME <br />ADpRESS <br />CITY <br />SJLHD CONTACT <br />RWQCB CONTACT <br />DHS CONTACT <br />&frii,ri,,/,-7/ IFMNE(/ <br />Z-7.6a40/ /7/17/ <br />-e 8,er7 7Z- <br />)\c....,k A / <br />rkeii Liqk ,(145 fr) <br />(STATE <br />PHONE <br />PHONE (2 /3) , <br />ZIP / <br />4/c <br />CONSULTANT I <br />5) 777- ..-2S--// <br />OTHER CONTACT