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PHS/SAN JOAQUIN COUNTY — ENVIRONMENTAL HEALTH DIVISION <br /> CONTAMINATED SITE MFR — INPUT FORM . <br /> UPDATE A/o /q,0 BY OfREv z EwED BY DATE ENTERED o?/,/��� IBY >,Ie <br /> ADDITION: EDIT: <br /> SWEEPS # I L5 COMPUTER # '("1 DIST # 3 LOC CODE 0 / <br /> UGT FILE X H W FILEJ LAND USE FILE PWS FILE PILOT PROD <br /> FAILED PT / / SOIL CONT 0 f/p /q p JGW CONT / / DW CONT <br /> PETROLEUM / N ENTERED PILOT / / FROG/ELEMENT <br /> SITE NAME eft!i r,, 1a rUr <br /> ADDRESS I to ') G - PHONEC-20V q-64-3311 <br /> CITY STATE CA ZIP 9J�05 <br /> CONTACT NAMEJ Cr, CROSS STREET tolls Gil <br /> PROPERTY OWNER <br /> NAME Jd rr7%Q, UiCCCv . [PHONEV�2) q&q, <br /> MAILING/STREET ADDRESS / 7.20 N rif Sk <br /> CITY Jan STATE C/� 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 /> GJ/EH CONTACT <br /> RWQCB CONTACT <br /> DHS CONTACT <br /> OTHER CONTACT <br /> UAR # qD — DATE / q / DATE <br /> STREET # J0�- SITE STREET PRIORITY <br /> cu 07 eV7^ �'7 f Q4 ' 1T t" •r •- -r r- � -ten•--ti r^-=, <br />