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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE / 0 10 BYOF* --I <br /> REVIEWED BY DATE ENTERED / / BY <br /> ADDITION: EDIT: <br /> SWEEPS # COMPUTER # DIST # `�Z U LOC CODE Q� <br /> UST FILE H W FILE LAND USE FILE PWS FILE PILOT PROG <br /> FAILED PT / / SOIL CONT l -) / ( /lO GW CONT �Z /d�( /10 DW CONT <br /> PETROLEUM Y / N ENTERED PILOT / / GROG/ELEMENT <br /> SITE NAME <br /> ADDRESS 3 �D PHONE <br /> CITY STATE CA Z I P <br /> CONTACT NAMET / CROSS STREET <br /> PROPERTY OWNER <br /> NAME --7 <br /> /; PHONE 2py- ydd _SG�Z` <br /> MAILING/STREET ADDRESS �Q <br /> CITY S> �✓� STATE �'� ZIP Q5770I <br /> CONTACT NAME PHONE 66- s(j Z/ <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME �, 9 �, PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT ��� �� ,� / �nsvl � PHONEYW7V- 2116 <br /> SJ/EH CONTACT <br /> RWQCB CONTACT �/ �✓ <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # - DATE / / PROP 65 # f o -06 S DATE //0 <br /> STREET # 3� SITE STREETPRIORITY <br /> EH 23 070 (7/89) 89-19 (IV)7/89 CNTMFR <br />