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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR - INPUT FORM . <br /> [UPDATE 1 /�a/�v BY °f REVIEWED BY DATE ENTERED <br /> ADDITIONr DIT: <br /> SWEEPS # 17 Q COMPUTER # 1�lg7�ek ?Q DIST # LOC CODE <br /> UST FILE yl <br /> H W FILE [LAND USE FILEA- , I <br /> PWS FILE PILOT PROS <br /> FAILED PT / / SOIL CONT !/ /a� /n GW CONT . / / DW CONT <br /> PETROLEUM Y / N ENTERED PILOT / / PROS/ELEMENT Z <br /> SITE NAME <br /> ADDRESS 7�0 -� �• � PHONE (aoq) ` -'16-4707 <br /> CITY /3,v STATE CA ZIP <br /> CONTACT NAME CROSS STREET <br /> PROPERTY OWNER <br /> e. <br /> NAME hNI�I.GG�►?IrS - ,�l`S�iftic PHONE <br /> MAILING/STREET ADDRESS �� 74 ���� f <br /> CITY I " JJ <br /> STATEZ IP a 3 <br /> CONTACT NAMEJ PHONE <br /> RESPONSIBLE PARTY (If different from Property Owner) <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY -7STATE ZIP <br /> CONSULTANT PHONE <br /> SJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # C) - 43 DATE 1 //a //� PROP 65 # 90 a e y DATE / /la /90 <br /> STREET # 17007 , SITE STREET �� �� � ��J PRIORITY <br />