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RHS/SAN JOAQUIN COUNTY — ENVIRONMENTAL .HEALTH DIVISION <br /> CONTAMINATED SITE MFR -- INPUT FORM <br /> UPDATE /�7/� BY REVIEWED BY .J DATE ENTERED ,� IL� /Cf ) BY <br /> ADDITION: EDIT; <br /> SWEEPS # / L AN/� COMPUTER # 1 . DIST # .23 LOC CODE <br /> UGT FILE G' H W FILELAND USE FILE PWS FILE PILOT FROG <br /> FAILED PT / / SOIL CONT /,23 GW CONT / 1 DW CONT <br /> PETROLEUM 0/ N ENTERED PILOT / / PROG/ELEMENT <br /> SITE NAME <br /> ADDRES5 Iva. _ PHONE <br /> CITY STATE CA ZIP <br /> CONTACT NAMEJ ��rr GJt'cz� CROSS STREET I A/c <br /> PROPERTY OWNER <br /> NAME �r PHONE <br /> MAILING/STREET ADDRESS <br /> CITY ff STATE 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 l <br /> RWQCB CONTACT <br /> i <br /> 1 <br /> DHS CONTACT <br /> OTHER CONTACT ° <br /> U A R # �r� — C� 2 DATE 65 # DATE 3 <br /> L <br /> STREET # SITE STREET (h,�., - qt-dr�`y CiJ�X. PRIORITY <br /> EH 23 070 (7/89) 89-19 (IV) 7/89 CNTMFR <br />