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/S`r,OAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVIS,`,,,, <br /> LOP PROGRAM - MFR INPUT FORM <br /> UPDATE • ' .� BY 'JS. REVIEWED BY DATE ENTERED BY <br /> ADDITION• EDIT:_ <br /> ENTERED PILOT SJ/PHS CONTACT SWEEPS # PRIORITY <br /> —7NOR SENT LOC CODE DIST PROGRAM/ELEMENT CODE 2� <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SUBSTANCE #1 5 <br /> SITE CODE �L�.� SOURCE OF FUNDS S / F FED EXEMPT Y / N PETROLEUM Y / N <br /> SITE NAME • tZC)71 ,SI •� , l�cV-L L DATE REPORTED <br /> ADDRESS '�� � ��- . 1DATE CONFIRMED <br /> CITY N ICA I ZIP C.�CJJ MULTIPLE RP's Y / N <br /> SITE STATUS <br /> CASE TYPE CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> U S G D 1 2 3 4 5 7 8 9 �p• � •�2. <br /> RP SEARCH S I N R DATE UNDERWAY COMPLETED <br /> PRELIMINARY ASSESSMENT U C DATE UNDERWAY CCMPLETED <br /> REMEDIAL INVESTIGATION U vx- DATE UNDERWAY COMPLETED <br /> REMEDIAL ACTION U I C DATE UNDERWAY COMPLETED <br /> POST REM ACT MONITORING Y N U C DATE UNDERWAY CCMPLETED <br /> ENFORCEMENT ACT TAKEN Y N ENFORCEMENT TYPE 1 2 3 4 5 6 DATE ACTION TAKEN <br /> LOFT CONSIDERATION 1 2 3 H S C A R W G 0 <br /> EXCAVATION STARTED CASE CLOSED T <br /> 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 PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> Additional RP's listed on REVERSE SIDE CONTAMINATED MFR INFO on REVERSE SIDE <br /> EH 23 083(09/89)REVISED 11/90 89-20(IV)01/90 PILMFA <br />