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PHS/Sr-'JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVIS <br /> LOP PROGRAM - MFR INPUT FORM <br /> 1^ BY <br /> UPDATE BY REVIEWED BY �vL ATE ENTERED <br /> ADDITION: EDIT: <br /> 1 <br /> ENTERED PILOT SJ/PHS CONTACT SWEEPS PRIORITY <br /> NOR SENT LOC CODE. DIST PROGRAM/ELEMENT CODEI- k <br /> SITE.SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SUBSTANCE #1 <br /> SITE CODE 2-�?j SOURCE OF FUNDS (5 J / F FED EXEMPT Y / PETROLEUM <br /> SITE NAME y F I� DATE REPORTED J[ <br /> ADDRESS V1 IV DATE CONFIRMED r� <br /> CITY CA 7 I Yl� MULTIPLE RP's Y / <br /> 1�3 SITE STATUS <br /> CASE TYPE CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> U S (3 D 1 2 3 4 5 7 8U9 <br /> RP SEARCH S I N R DATE UNDERWAY COMPLETED <br /> PRELIMINARY ASSESSMENT U C DATE UNDERWAY COMPLETED <br /> REMEDIAL INVESTIGATION U 4[G DATE UNDERWAY COMPLETED <br /> REMEDIAL ACTION U I C DATE UNDERWAY COMPLETED jam` <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 3 N _ 5 C A R W G 0 <br /> EXCAVATION STARTED 0 <br /> CASE CLOSED R H DATE CLOSED <br /> REMEDIAL ACTION TAKEN co CB ED ET FP GT IT RS HU NA YS <br /> primary / Additional RESPONSIBLE PARTY <br /> PHONE <br /> COMPANY NAME <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> SE TIP <br /> CITY TAT <br /> Additional RP's Listed on REVERSE SIDE C)NTAMINATED MFR INFO on REVERSE SIDE <br /> 89 20([V)01/90 PILMFA <br /> EH 23 083(09/89)REVISED 11/90 a <br /> 1 <br />