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PH�AN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIJON <br /> LOP PROGRAM - MFR INPUT FORM <br /> UPDATE BY JREVIEWED BY �— DATE ENTERED <br /> ADDITION: <br /> EDIT: �7T" <br /> ENTERED LOP �A SJ/PHS CONTACT �� / [PRIORITY <br /> /G G1Cl <br /> NOR SENT ` c� LOC CODE I DIST PROGRAM/ELEMENT CODE <br /> ! SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SUBSTANCE #1 <br /> SITE CODE �r SOURCE OF FUNDSS / F FED EXEMPT Y / N PETROLEUM Y / N <br /> SITE NAME S DATE REPORTED / G <br /> ADDRESS DATE CONFIRMED Z Z <br /> C17Y o CA ZIP � rf�/ MULTIPLE RP'8 Y / N <br /> SITE STATUS •/C l� <br /> CASE TYPE �-� CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> U S G D 1 / 3 J 4 5 7 8 9 e <br /> RP SEARCHS I N R DATE UNDERWAY COMPLETED <br /> //7/7 <br /> PRELIMINARY ASSESSMENTU C DATE UNDERWAY COMPLETED <br /> REMEDIAL INVESTIGATION U C 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 S A R W G 0 <br /> EXCAVATION STARTED CASE CLOSED Y R H DATE CLOSED r <br /> REMEDIAL ACTION TAKE), CD CB ED ET FP GT IT RS HU NA VS <br /> _rte Primary")4 Additional RESPONSIBLE PA <br /> COMPANY NAME PHONE 2—d f / t ` �b6 <br /> CONTACT NAME r � Q PHONE r <br /> ADDRESS t� <br /> CITY STATE ZIP ��� <br /> s �J <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 />