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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> PILOT PROGRAM - MFR INPUT FORM <br /> UPDATE <br /> BY uf'LL REVIEWED 8Y DATE ENTERED <br /> ' BY <br /> ADDITION:__ EDIT:�~ <br /> ENTERED PILOT SJ-PHS CONTACT <br /> S4IEEPS N 2r(TIS- PRIORITY <br /> COMP 8 ( LOC CODE <br /> DIST PROG/ELEMENT CODE _ �� <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR R 39000 SOI Of FUNDS <br /> S / F SUBSTANCE <br /> SITE CODE <br /> FED EXEMPT Y / N PETROLEUM Y / N <br /> SITE NAME <br /> DATE REPORTED <br /> ADDRESS Z <br /> (� DATE CONFIRMED <br /> CITY <br /> CA 2IP CATEGORY R / S <br /> SITE STATUS <br /> CASE TYPE <br /> CONTRACT STATUS EMERGENCY RESPONSE <br /> U S G D 1 2 3 4 S T 8 9 <br /> RP SEARCH S 1 N R DATE UNDERWAY <br /> COMPLETED <br /> PRELIMINARY ASSESSMENT U nc <br /> DATE UNDERWAY n <br /> COMPLETED <br /> REMEDIAL INVESTIGATION U DATE UNDERWAY ` v <br /> COMPLETED <br /> REMEDIAL ACTION U I C DATE UNDERWAY <br /> COMPLETED <br /> lj// / <br /> POST REM ACT MONITORING Y N U C DATE UNDERWAY COMPLETED ` <br /> ENFORCEMENT ACT TAKEN Y N ENFORCEMENT TYPE 1 2 3 4 S 6 DATE ACTION TAKEN <br /> LOFT CONSIDERATION 1 2 3 H S C A R W G 0 <br /> EXCAVATION STARTED CASE CLOSEDY R H DATE CLOSED It <br /> REMEDIAL ACTION TAKEN CD CB ED CE T) FP GT IT RS HU NA VS <br /> RESPONSIBLE PARTY <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY [STATE ZIP <br /> r -tea. <br /> 23 083(09/89)REVISED 01.190 - , <br /> 111111/90 PILMFR <br />