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w JOAQUIN LOCAL HEALTH DISrNiCT <br /> -.PILOT PROGRAM - MFR INPUT FORM <br /> UPDATE . / / BY DATE ENTERED <br /> ADDITION: EDIT: DELETE: <br /> COMP # �D' t. LOC CODE (),3 DI ST"6 6Z�ROG/ELEMENT CODE 23� <br /> ENTERED PILOT! /C)+/ O CONTAM MFR FILED QY / N PRIORITY <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR ,# 39000 SOURCE OF FUNDS @) / F SUBSTANCE <br /> SITE CODE # Z2� -z- FED EXEMPT Y / © PETROLEUM Y / N <br /> DATE REPORTED DATE CONFIRMED 8� J©Z/ CATEGORY a / S <br /> SITE NAME <br /> ADDRESS r <br /> CITY STATE CA ZIP <br /> SITE STATUS <br /> CASE TY/PPE CONTRACT STATUS EMERGENCY RESPONSE <br /> U / S / / D 1 2 3 5 6 7 8 <br /> RP SEARCH ©/ I / N / R DATE UNDERWAY ( /©Q /® COMPLETED <br /> PRELIM ASSESSMNT Y `J CCDATE UNDERWAY / g/ Z(p COMPLETED <br /> REMEDIAL INVEST �U / C DATE UNDERWAY S�P /O� / Zq COMPLETED <br /> REMEDIAL ACTION ® / C J!LTE UNDERWAY / / COMPLETED <br /> DATE EXCAVATION STARTED 84/ fZ/2� REMEDIAL ACTIONS TAKEN 5 <br /> POST REMEDIAL ACTION MONITORING Y / N / U / C <br /> POST REMED ACT MONITOR DATE UNDERWAY / / COMPLETED <br /> ENFORCE ACT TAKEN Y / N DATE UNDERWAY / / COMPLETED <br /> ENFORCEMENT ACTION TYPE 1 / 2 / 3 / 4 / 5 / 6 <br /> CASE CLOSED Y / R / H DATE CASE CLOSED <br /> RESPONSIBLE PARTY <br /> CONTACT NAME G PHONE .. <br /> COMPANY NAME �© lPHONE <br /> ism ULE�A es <br /> ADDRESS <br /> CITY STATE ZIP 9524v <br /> 89-020 (IV) 5/89 PILMFR <br />