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PHS/SAIrlvAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISIOi� <br /> C'-16-p IAP�-RR9QR�1M - MFR INPUT FORM , <br /> UPDATE l BY `m0 REVIEWED BY DATE ENTERED JUL 21 199 BY <br /> -j 1 <br /> ADDITION• EDIT: <br /> ENTERED-kEP' -7113193 SJ/PHS CONTACT PRIORITY <br /> -ri -T-� <br /> NOR SENT LOC CODE DIST PROGRAM/ELEMENT CODE q 5 l <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR * 39000 SUBSTANCE #1 <br /> SITE CODE �3�a�� SOURCE OF FUNDS S / F FED EXEMPT Y / N PETROLEtIMI Y / N <br /> . 1 DATE REPORTED <br /> SITE NAME w <br /> ADDRESS C� ( DATE CONFIRMED l l <br /> CITY CA 21P S oZ3� 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 4 5 6 7 8 �� q3 <br /> RP SEARCH 0 I N R DATE UNDERWAY L1q � 3 COMPLETEDPRELIMINARY ASSESSMENT UC DATE UNDERWAY -7 � �l3 COMPLETED <br /> REMEDIAL INVESTIGATION U C DATE UNDERWAY COMPLETED <br /> REMEDIAL ACTION U I 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 C L DATE CLOSED <br /> REMEDIAL ACTION TAKEN CD CB ED ET FP GT IT RS HU NA VS VE NT OT UK <br /> —Zprimary / Additional RESPONSIBLE PARTY <br /> COMPANY NAME C � PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY l STATE ZIP sp <br /> Additional RP's listed on REVERSE SIDE CONTAMINATED MFR INFO on REVERSE SIDE <br /> EN 23 083(09/89)REVISED 8/92 89-20(IV)01/90 PILMFA <br />