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PHS/SAN JOA-Vo,IN COUNTY - ENVIRONMENTAL----a• ALTH DIVISION <br /> PILOT PROGRAM - MFR INPUT FORM <br /> UPDATE / 5 / IBY 01 . LY od JDATE ENTEREDIBY <br /> ADDITION: EDIT: DELETE: <br /> COMP # C 5 LOC CODE 1 03 DIST c/3 ROG/ELEMENT CODE <br /> ENTERED PILOT j/ / �6 / flCONTAM MFR FILED Y / N PRIORITY <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SOURCE OF FUNDSS / F SUBSTANCE z1 <br /> SITE CODE # /�6/.3 _ FED EXEMPT Y / No PETROLEUM / N <br /> DATE REPORTED / / DATE CONFIRMED CATEGORY O / S <br /> SITE NAME <br /> ADDRESS �-� HA -21VC(, <br /> CITY STATE CA ZIP 9 5 3 7 6 <br /> SITE STATUS <br /> CASE TYPE CONTRACT STATUS EMERGENCY RESPONSE <br /> U / S / G /0D 1 2 3 4 5 6 7 8 <br /> RP SEARCH S / I / N / R DATE UNDERWAY COMPLETED <br /> PRELIM ASSESSMNT (U / C DATE UNDERWAY COMPLETED <br /> REMEDIAL INVEST U / C DATE UNDERWAY / / COMPLETED <br /> REMEDIAL ACTIONU / C DATE UNDERWAY / / COMPLETED <br /> DATE EXCAVATION STARTED / / REMEDIAL ACTIONS TAKEN <br /> POST REMEDIAL ACTION MONITORING Y / N / U / C <br /> POST REMED ACT MONITOR DATE UNDERWAY / / COMPLETED <br /> ENFORCE ACT TAKEN Y / N DATE UNDERWAY / / COMPLETED <br /> ENFORCEMENT ACTION TYPE 1 / 2 / 3 / 4 / 5 / 6 <br /> CASE CLOSED Y / R / H DATE CASE CLOSED <br /> RESPONSIBLE PARTY <br /> COMPANY NAME / PHONE <br /> CONTACT NAME L PHONE L/15 !12 b/- Z Z <br /> ADDRESS - <br /> CITY pjSTATE ZIPy- <br /> //,Orj .-- <br /> EH 23 083 (6/89) 89-20 (IAPrS/89 PILMFR N""', <br />