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V S/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> PILOT PROGRAM - MFR INPUT FORM <br /> E <br /> DATE ?a p BY /� �y� REVIEWED BY DATE ENTERED <br /> BY <br /> ADDITION:— EDIT: <br /> ENTERED PILOT �EC ?�.' SJ-PHS CONTACT SWEEPS # /3 PRIORITY <br /> COMP # rn A C G LOC CODE D DIST 3 R Y PROG/ELEMENT CODE 3 S O <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SOURCE OF FUNDS / F SUBSTANCE _9 3 y <br /> —T— <br /> SITE CODE /�_ FED EXEMPT Y / l PETROLEUM YO / N <br /> SITE NAME l� <br /> r e t C,ul i24NS x DATE REPORTED / OL S <br /> ADDRESS S S DATE CONFIRMED / 0 2/'s <br /> CITY CA ZIP S3 CATEGORY / S <br /> SITE STATUS <br /> CASE TYPE CONTRACT STATUS EMERGENCY RESPONSE <br /> U S GO D 1 2 4 5 7 8 9 <br /> RP SEARCH OS I N R DATE UNDERWAY gly COMPLETED <br /> 7 <br /> PRELIMINARY ASSESSMENT 0 C DATE UNDERWAY J/ o COMPLETED <br /> REMEDIAL INVESTIGATION U C DATE UNDERWAY C0 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 ON ENFORCEMENT TYPET-1 2 3 4 5 6 DATE ACTION TAKEN <br /> LUFT CONSIDERATION •1 ® �S R W G 0 <br /> EXCAVATION STARTEDJAk �� ! CASE CLOSED Y R H DATE CLOSED <br /> REMEDIAL ACTION TAKEN CD CB ED ET FP GT 1T RS HU NA VS <br /> RESPONSIBLE PARTY <br /> COMPANY NAME / PHONE <br /> CONTACT NAME Q L PHONE ( _ Z2 <br /> ADDRESS <br /> CITY �/� LJ�.�-� STATE ZIP <br /> EH 23 083(09/89)REVISED 01/90 <br /> 89-20(IV)01/90 PILMFR �� I <br />