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PHS/. JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVI: <br /> CAP PROGRAM - MFR INPUT FORM <br /> 9 gY REVIEWED BY DATE ENTERED BY <br /> UPDATE i 5 i <br /> ADDITION: EDIT: �•� <br /> SITE CODE q6 l� PROGRAM/ELEMENT 2 2� Tv LOC CODE DIST PRIORITY <br /> 10 1 ENTERED CAP _/ SJ/EH CONTACT INITIAL REVIEW FEE PD <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> SUBSTANCE #1F 2 3 5 PETROLEUM Y / N <br /> FED EXEMPT Y / N LEAD AGENCY <br /> SITE NAME DATE REPORTED <br /> ADDRESS I DATE CONFIRMED <br /> CITY _ CA ZIP MULTIPLE RP's Y / N <br /> SITE STATUS <br /> CASE TYPE SITE STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> U S G D 1 2 3 4 5 7 8 9 <br /> RP SEARCH S 1 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 7N ] 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 H DATE CLOSED <br /> REMEDIAL ACTION TAKEN CD CB ED ET FP GT IT RS HU NA VS <br /> Primary / Additional RESPONSIBLE PARTY <br /> COMPANY NAME PHON7- <br /> CONTACT <br /> NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> Additional RP's listed on REVERSE SIDE CONTAMINATED MFR INFO on REVERSE SIDE <br /> EH 23 (03/91)IV CAPMFR <br />