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PHS JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIV, <br /> LOP PROGRAM - MFR INPUT FORM <br /> [UPDATE t . l��� IBY REVIEWED BY DATE ENTERED / &/ BYT& <br /> ADDITION: EDIT• ! / <br /> ENTERED PILOT 2 _23-qO SJ/PHS CONTACT �, �l�l SWEEPS # /M7 PRIORITY <br /> COMP # CoCpir, ` ' LOC CODE E�5 PROGRAM/ELEMENT CODE �L 34q <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SUBSTANCE #1 1 /2 O 3�o 2 1 5 <br /> SITE CODE SOURCE OF FUNDS S / V FED EXEMPT Y / CN) PETROLEUM / N <br /> SITE NAME c0c4q w!Vo +c, (3Dr LItAC DATE REPORTED ¢/ 1 o?o <br /> ADDRESS I Lwkl wAiA DATE CONFIRMED "1/ 1/ NO <br /> CITY CA ZIP G�(?JVJ� MULTIPLE RP's Y <br /> SITE STATUS <br /> CASE TYPE CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> U S OG D 1 2 3 4 �5 7 8 9 <br /> RP SEARCH-'[ r S ) I N R DATE UNDERWAY b r7 3/go COMPLETED q / <br /> PRELIMINARY ASSESSMENT U C DATE UNDERWAY (� + Q O COMPLETED <br /> REMEDIAL INVESTIGATION U U DATE UNDERWAY CJ 7 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 N ENFORCEMENT TYPE 1 2 3 4 5 6 DATE ACTION TAKEN <br /> LUFT CONSIDERATION 1 2 0 ( ) ( OC 0 aR V 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 )per PHONE <br /> CONTACT NAME STCvL PHONE L4-� <br /> ADDRESS 14466 <br /> CITY slam - �- ! '1� �d1=�iW STATE Cm ZIP "i�.d•4 <br /> Additional RP's listed on REVERSE SIDE CONTAMINATED MFR INFO on REVERSE SIDE ✓ <br /> EH 23 083(09/89)REVISED 11/90 89-20(IV)01/90 PILMFA <br />