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._. ..r <br /> PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM <br /> n <br /> UPDATE 12j,/f/ I RY REVIEWED BYjl-cn�l <br /> DATE ENTERED /�� / BY <br /> ADDITION: EDIT. <br /> SWEEPS # ( COMPUTER # C4jFQ6q DIST # ?j�`� LOC CODE Q <br /> UGT FILE X H W FILE LAUD USE FILE PWS FILE PILOT PROD <br /> FAILED PT / / SOIL CONT / / GW CONT / / DW CONT <br /> PETROLEUM CY / NI <br /> ENTERED PILOT / / PROG/ELEMENT <br /> SITE NAME � �� 5 <br /> ADDRESS 6 i/ �--- �f F'WONE <br /> CITYfc�- ` ( STATE Z I P <br /> CONTACT NAME � (p cd,ly�,D _ CROSS STREET O K <br /> PROPERTY OWNER <br /> NAME I fl,IID /111�/��ohl P PHONE I qL(3 1636 <br /> MAILING/STREET ADDRESS 6 ,q Z— <br /> CITY 5T0���Ql� STATE Cj+- JZIPJ ^) <br /> CONTACT NAME �J j44 L? C�414r43 PHONE e.(�_�633 Z� <br /> RESPONSIBLE PARTY ( If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY w STATE ZIP <br /> CONSULTANT PHONE <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR it Igo — DATE 1.2-110 PROP 65 # — DATE /1A / /-0-T6 <br /> STREET # SITE STREET ��✓✓ PRIORITY <br /> EH 23 070 (7/Aq) Aq--1 q t r U 1 7 iaa rnITnnc-cr <br />