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PHS SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> PILOT PROGRAM. - MFR INPUT FORM <br /> UPDATE BY PREVIEWED BY .� DATE ENTERED BY 7 ZL70 1 <br />�< ADDITION: EDIT:, <br /> ENTERED PILOT SJ-PHS CONTACT SWEEPS q =PRIORITY <br /> l COMP # LOCCODE DIST PROG/ELEMENT CODE <br /> SITE?SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SOURCE OF FUNDS S / F SUBSTANCE <br /> SITE CODE �;;� L FED EXEMPT Y / N PETROLEUM Y / N <br /> F <br /> Ik <br /> SITE NAME _ [,!r DATE REPORTED <br />` ADDRESS Cif �� �d1N1 UUU flf... �J Y�/ DATE CONFIRMED <br /> CITY �vN GA ZIP �tJ'a 3/ CATEGORY R �S <br /> �U <br /> SITE STATUS <br /> CASE TYPE I, CONTRACT STATUS EMERGENCY RESPONSE <br /> U S G D 1 2 3 4 .5 7 B 9 <br /> RP SEARCH S 1 N R DATE UNDERWAY COMPLETED <br /> PRELIMINARY ASSESSMENT U C DATE UNDERWAY COMPLETED <br /> 4 <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 /> t �3 <br /> ENFORCEMENT ACT TAKEN Y N ENFORCEMENT TYPE 1 2 3 4 5 6 DATE ACTION TAKEN <br />{ <br /> LUFT CONSIDERATION 1 2 3 H S C A R W G 0 <br />} EI(CAV TION STARTED CASE CLOSED Y R H DATE CLOSED' <br /> REMEDIAL ACTION TAKEN CD CB ED ET FP GT IT. RS HU NA VS <br /> i RESPONSIBLE PARTY <br /> COMPANY NAME [.� PHONE <br /> CONTACT_NAME fYt hn u n <br /> [. ADDRESS / Y <br /> 41. <br /> CITY STATE, -py''; <br /> �t <br /> 40 <br /> 1 <br />! EH 23 083(09/89)REVISED 01/40 <br /> 89-20(IV)01/90 PILMFR #, r'•I <br /> g <br />