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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISIOA+ =p <br /> CONTAMINATED SITE MFR - INPUT FORM , <br /> BYJ REVIEWED BY DATE ENTERED 1-7 2- BY <br /> ADDITION:_ DIT: <br /> SWEEPS # ) 4c) COMPUTER # C �r DIST # LOC CODE <br /> UST FILE H W FILEJ LAND USE FILE PWS FILE PILOT PROfl <br /> FAILED PT / / SOIL CONT / / JGW CONT / / DW CONT <br /> PETROLEUM Y / N O, / 1� qo I �3 <br /> SITE NAMEJ� <br /> ADDRESS 99 <br /> 1 11PHONE <br /> 0 11D <br /> CITY STATE CA ZIP <br /> CONTACT NAME CROSS STREET <br /> PROPERTY OWNER <br /> NAME ,Q PHONE <br /> MAILING/STREET ADDRESS <br /> CITYOXIJ STATE 2IP 9 3032 <br /> CONTACT NAME IAPHONE <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> DHS CONTACT <br /> v <br /> DATE !`/ `I / PROP 65 # 1 % - gn8 l DATE 5 //j <br /> STREET # SITE STREET Vj �U PRIORITY <br /> EH 93 .070 (1/89) 89-19 (IV)7/89 CNTMFR <br />