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PHSj,./JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVI�, �J <br /> LDP PROGRAM - MFR INPUT FORM <br /> UPDATE BY REVIEWED BY DATE ENTERED �, BY <br /> I II <br /> ADDITION• � EDIT: 16E <br /> ENTERED PILOT Jn� �ZSJ/PHS CONTACT S, SCJ �YL� SWEEPS -5 77 PRIORITY <br /> NOR SENT LOC CODEDIST �23 <br /> SITEPROGRAM/ELEMENT CODE 2! Z 7 <br /> r !SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR * 39000 SUBSTANCE #1 (or•O f03 V5 <br /> SITE CODE Z�j 77 SOURCE OF FUNDS S / 0 <br /> FED EXEMPT Y / PETROLEUM 6) / N <br /> SITE NAME / •�.lL . . ..✓1 DATE REPORTED lb t <br /> ADDRESS �'1Wl.Gl�• DATE CONFIRMED f0 <br /> I <br /> CITY CA ZIP MULTIPLE RP's Y / N <br /> SITE STATUS <br /> CASE TYPE CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> 1 <br /> U (!) G Ah <br /> 1 2 6) 4 5 T 6 9 /� 2 <br /> ISI f <br /> , <br /> RP SEARCH / h I N R DATE UNDERWAY COMPLETED <br /> PRELIMINARY ASSESSMENT U C DATE UNDERWAY COMPLETED <br /> REMEDIAL INVESTIGATION U wG DATE UNDERWAY COMPLETED <br /> REMEDIAL ACTION U 1 C DATE UNDERWAY COMPLETED <br /> POST REM ACT MONITORING Y N U C DATE UNDERWAY COMPLETED <br /> ENFORCEMENT ACT TAKEN Y N ENFORCEMENT TYPE 1 2 3 4 5 6 DATE ACTION TAKEN <br /> LUFT CONSIDERATION 1 2 3 H S C A R W G 0 <br /> EXCAVATION STARTED CASE CLOSED Y R H DATE CLOSED <br /> REMEDIAL ACTION TAKEN CD CS ED ET FP GT IT RS HU NA VS <br /> Primary / Additional RESPONSIBLE PARTY <br /> COMPANY NAME f; 1A T�4 K. PHONE <br /> CONTACT NAME PHONE n q4%r 6S00 <br /> ADDRESS (J"r <br /> 126 <br /> CITY 0, STATE ZIP 4'S'tos <br /> Additional RP's listed on REVERSE SIDE CONTAMINATED MFR INFO on REVERSE SIDE Y <br /> EH 23 083(09/89)REVISED 11/90 89-20(IV)01/90 PI <br />