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PHS/SAN JOAQUIN COUNTY — ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE' MFR — INPUT FORM <br /> Lp <br /> DATE f� /I6 /5 BY REVIEWED BY DATE ENTERED <br /> 112-1 T/ �7 BY <br /> ADDITION: EDIT: <br /> SWEEPS # _ COMPUTER # �� S� DIST # �3 LOC CODED <br /> UST FILEH W FILE LAND USE FILE PWS FILE PILOT FROG <br /> FAILED PT / / SOIL CONT 12S." / GW CONT / / DW CONT <br /> PETROLEU / N ENTERED PILOT �l / j 621FROG/ELEMENT zi <br /> SITE NAME A <br /> // ss "-.. i <br /> ADDRESS r 6-7, W�jS PHONE ,/! r <br /> CITY STATE CA IP <br /> CONTACT NAMErV l� y��[f �, J�L, I CROSS STREET w <br /> PROPERTY OWNER <br /> NAME ; PHONE <br /> i 4 <br /> MAILING/STREET ADDRESS " I <br /> CITY j STATE ZIP <br /> i <br /> CONTACT NAME RHONE <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY JSTATE IZIpf it <br /> CONSULTANT " <br /> aQ�/l i PHDNE ��� 3�G <br /> SJ/EH CONTACT <br /> RWQCB CONTACT —fes <br /> y <br /> AHS CONTACT <br /> OTHER CONTACT <br /> UAR # 9 —��� DATE 17 �j / C PROP 65 <br /> 7j7,# DATE / <br /> 1 — <br /> STREET #`; � 6ITE STREET LlS PRIORITY. <br />