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PHS/SAN JOAiUIN COUNTY - ENVIRONMENTAL"rHEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM ? <br /> UPDATE S/ D BY REVIEWED BY DATE ENTERED r*, <br /> jy / BY <br /> ADDITION: EDIT: <br /> SWEEPS # I7� COMPUTER # DIST # Z o LOC CODE Q <br /> UST FILE 4H W FILE LAND USE FIL <br /> E PWS FILE PILOT PROG <br /> FAILED PT / / SOIL CONT / /2 GW CONT / / DW CONT <br /> PETROLEUM Y / N ENTERED PILOT / / GROG/ELEMENT <br /> SITE NAME <br /> ADDRESS �OZ l�A[�vuT- GT PHONE <br /> CITY J STATE CR ZIP <br /> CONTRCT NAME W R CROSS STREET <br /> PROPERTY OWNER <br /> NAME �JA� / PHONE I (ql _Z/ <br /> MAILING/STREET ADDRESS <br /> CITY STATE C.+ I <br /> ZIF' gx157 � <br /> CONTACT NAME M PHONE yl <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME S PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STRTE ZIP <br /> CONSULTANT PHONE <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # - DATE g-/a9 /0,0 PROP 65 # - DATE <br /> STREET # SITE STREET lV� �U� PRIORITY <br /> EH 23 070 (7/89) 89-19 ( IV) 7/89 CNTMFR <br />