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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL-HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM . <br /> UPDATE p�1�s/f'v BY - REVIEWED BY12�DATE ENTERED / / By <br /> ADDITIONa i� EDIT. <br /> SWEEPS # alfZI4 COMPUTER # 4/yh Cotzi'l' DIST # �2� JLOC CODE <br /> UGT FILE H W FILE LAND USE FILEPWS FILE PILOT PROG <br /> FAILED PT / / SOIL CONT / /fa /p0 GW CONT I DW CONT <br /> PETROLEUM Y / N ENTERED PILOT / / GROG/ELEMENT <br /> SITE NAME D <br /> ADDRESS a S7'- PHONE I(aloq)�711— f <br /> CITY ' -fo c-)c4t�'A� STATE CA Z IP_j <br /> CONTACT NAME if Y1 Q- e J.CROSS STREET i3 <br /> PROPERTY OWNER <br /> NAME RHONE <br /> MAILINGtSTREEF ADDRESS o4 a <br /> CITY STATE 0. 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 # �� - 21 DATE o� / �J /<� 'ROP 65 # U '" ,D J 0 DATE p� 115- �0 <br /> STREET # g p� 7 <br /> ATE STREET �gS7 jj� PRIORITY <br /> EH 23-07.0 -'.(7/A9j_ Aq-i 4 t T u%'7 iu4 _rniTMC0 <br />