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PHN(N JOAQUIN COUNTY - ENVIRONMENTAL HEALTH D1VIMI'ON <br /> LOP PROGRAM - MFR INPUT FORM <br /> UPDATE ���f d BY REVIEWED BY DATE ENTERED 162cl �/ 4l BY <br /> ADDITION: EDIT: <br /> ENTERED LOP SJ/PHS CONTACT PRIORITY <br /> NOR SENT LOC CODE DIST PROGRAM/ELEMENT CODE <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SUBSTANCE 01 <br /> SITE CODE D SOURCE OF FUNDS S / F FED EXEMPT Y / N PETROLEUM Y / N <br /> SITE NAME DATE REPORTED <br /> ADDRESS DATE CONFIRMED <br /> CITY ` CA ZIP GJ/� 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 <br /> RP SEARCH S I N R DATE UNDERWAY COMPLETED <br /> PRELIMINARY ASSESSMENT U C DATE UNDERWAY 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 N DATE CLOSED <br /> REMEDIAL ACTION TAKEN CD CB ED ET FP GT IT RS HU IAA VS <br /> Primary / Additional RESPONSIBLE PARTY <br /> COMPANY NAME <,� n n PHONE <br /> CONTACT NAME ' PHONE N L[ — 2 �-3 <br /> ADDRESS P o p �1 J J 4 q <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 />