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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> PILOT PROGRAM - NFR INPUT FORM <br /> UPDATE /L?� BY REVIEWED BY `,, DATE ENTERED BY <br /> ADDITION: EDIT: <br /> ENTERED PILOT SJ-PHS CONTACT �J' sC,4'Q(fn)LjA,,I SWEEPS # PRIORITY <br /> COMP A n��li J� � V LOC CODE � DIST 3?j3 PROG/ELEMENT CODE <br /> �/ SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR N 39000 SOURCE OF FUNDS S / 0 <br /> SUBSTANCE <br /> SITE CODEf2 I FED EXEMPT Y / PETROLEUM Y� / N <br /> SITE NAME �j¢�1 ,. C ,vZ� L/d. / DATE REPORTED <br /> ADDRESS r 00 tj DATE CONFIRMED r I a <br /> CITY CA I ZIP CATEGORY ®R / S <br /> SITE STATUS <br /> CASE TYPE CONTRACT STATUS EMERGENCY RESPONSE <br /> U S G D 1 `2 3 4 5 7 8 9 <br /> RP SEARCH OS I N R DATE UNDERWAYQ S3 /, COMPLETED <br /> PRELIMINARY ASSESSMENT (Al) C DATE UNDERWAY YA 6 `J COMPLETED <br /> REMEDIAL INVESTIGATION U C DATE UNDERWAY D b COMPLETED <br /> REMEDIAL ACTION U 1 C DATE UNDERWAY COMPLETED <br /> POST REM ACT MONITORING Y N U C DATE UNDERWAY COMPLETED <br /> ENFORCEMENT ACT TAKEN Y U ENFORCEMENT TYPE 1 2 3 4 5 6 DATE ACTION TAKEN <br /> LUFT CONSIDERATION 1 O 3 �H CS) a V o 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 /> !, / <br /> RESPONSIBLE PARTY <br /> COMPANY NAME /'�7 - J��W l �Y%•�% I�Nl/ PHONE <br /> CONTACT NAME ww 9/cff. ! PHONE 4-(a <br /> ADDRESS I V�� <br /> C I TY � STATE 21 P 9 as z-1 <br /> EH 23 083(09/89)REVISED 01/90 <br /> 89-20(IV)01/90 PILMFR <br />