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PHS JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVIIwj <br /> LOP PROGRAM - MFR INPUT FORM <br /> :I <br /> UPDATE BY 4 ` yvl,� REVIEWED BY `.ys. DATE ENTERED ' % gY <br /> ADDITION: EDIT- <br /> ENTERED LOP SJ/AHS CONTACT /� PRIORITY <br /> NOR SENT 9• L/ LOC CODET3 DIST PROGRAM/ELEMENT CODE z <br /> I 11 <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION p <br /> CONTRACTOR alt 39000 SUBSTANCE #1 O 2 3 r <br /> SITE CODE ZSOURCE OF FUNDS 5 / F FED EXEMPT Y / /N 1 PETROLEUM Y / N <br /> SITE NAME DATE REPORTED <br /> m <br /> ADDRESS DATE CONFIRMED <br /> CITY CA ZIP - MULTIPLE RP's Y7 <br /> / G <br /> S1TE STATUS <br /> CASE TYPE CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> r <br /> U so G D 1 2 3 4 5 6 T 8 <br /> RP SEARCH 1 N R DATE UNDERWAY 4*Y �G COMPLETED 4'r <br /> PRELIMINARY ASSESSMENT U C DATE UNDERWAY d• / COMPLETED lJ 6 <br /> REMEDIAL INVESTIGATION U C DATE UNDERWAY COMPLETED I <br /> REMEDIAL ACTION U 1 C DATE UNDERWAY COMPLETED j <br /> �i <br /> POST REM ACT MONITORING Y N U C DATE UNDERWAY COMPLETED <br /> ENFORCEMENT ACT TAKEN Y N ENFORCEMENT TYPE r+ 1 2 3 4 5 6 DATE ACTION TAKEN <br /> y <br /> LUFT CONSIDERATION 1 2 3 S C y(A ®R W G 0 67- <br /> EXCAVATION STARTED W e CASE CLOSED Y R5] s C' �L DATE CLOSED <br /> I <br /> REMEDIALACTIDN TAKEN CD CCB ED ET FP GTS 1T RS -�' HU NA ` `VS -YE MT OT �UK <br /> Primary / Addition{RESPONSIBLE PARTY i <br /> COMPANY NAME' Q� `�) PHONE 1'76 <br /> J 7 h <br /> CONTACT NAME / ./1 � �. PHONE <br /> ADDRESS <br /> CITY Y� y STATE\ /ZD 2IP F� <br /> Leis '�f <br /> Additional RP's listed on REVERSE SIDE a CONTAMINATED MFR INFO On REVERSE SIDE <br /> EH 23 083(09/89)REVISED 8/92 89-20(IV)01/90 PILMFA <br />