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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> UPDATE /`/ JBYJ REVIEWED BY DATE ENTERED �,/ 51 l/ BY <br /> ADDITION• ✓ EDIT: <br /> SWEEPS # l C3 COMPUTER # 1 rl-APi DIST # 1 q,/X LOC CODE <br /> II - <br /> UGT FILE I/ H W FILE LAND USE FILE PWS FILE PILOT PROG <br /> FAILED PT / / SO I L CONT Z/ // / ��, GW CONT Z //7 DW CONT <br /> PETROLEUM �/ N ENTERED PILOT PROG/ELEMENT <br /> SITE NAME <br /> ADDRESS / �6 6 /q f, '� PHONE (2Uj) yGG <br /> CITY �7'n�l' - STATE CA ZIP <br /> CONTACT NAME CROSS STREET <br /> PROPERTY OWNER <br /> NAME Ell � �t�, PHONE <br /> MAILING/STREET ADDRESS (l��� <br /> CITY STATE CA ZIP <br /> CONTACT NAME PHONE li-o-7) va- <br /> RESPONSIBLE PARTY ( If different from Property Owner) <br /> COMPANY NAME - PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> CONSULTANT ( <br /> PHONE 11�) -70 <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # — DATE ? / S� / PROP 65 # — DATE <br /> STREET # SITE STREET .ytG �Co PRIORITY <br /> EH 23 .070 (7/89) 89-19 ( IV) 7/89 CNTMFR <br />