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� I <br />PHS/'M)JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br />LOP PROGRAM - MFR INPUT FORM <br />UPDATEji��By [ REVIEWED BY �� DATE ENTERED � �//j BYY& I <br />ADDITION: EDIT: L� <br />SITE SPECIFIC QUARTERLY REPORT INFORMATION <br />CONTRACTOR # 39000 <br />SUBSTANCE #1 <br />DATE REPORTED <br />EMERGENCY RESPONSE <br />ADDRESS�•c•') <br />�* <br />ENTERED LOP <br />RP SEARCH S I N R <br />SJ/PHS CONTACT <br />s. <br />PRIORITY <br />SOURCE OF FUNDS S / F. <br />NOR SENT <br />Y / N <br />LOC CODE <br />Y / N <br />DIST <br />PROGRAM/ELEMENT CODE <br />SITE SPECIFIC QUARTERLY REPORT INFORMATION <br />CONTRACTOR # 39000 <br />SUBSTANCE #1 <br />DATE REPORTED <br />EMERGENCY RESPONSE <br />ADDRESS�•c•') <br />�* <br />DATE CONFIRMED <br />RP SEARCH S I N R <br />CITY <br />SITE CODE <br />` <br />SOURCE OF FUNDS S / F. <br />FED EXEMPT <br />Y / N <br />PETROLEUM <br />Y / N <br />SITE NAME <br />r; <br />1 <br />DATE REPORTED <br />EMERGENCY RESPONSE <br />ADDRESS�•c•') <br />�* <br />DATE CONFIRMED <br />RP SEARCH S I N R <br />CITY <br />-q y CA <br />ZIP <br />cis <br />FgJLTIPLE RP's <br />Y / N <br />SITE STATUS <br />CASE TYPE <br />CONTRACT STATUS <br />STATUS CHANGE DATE <br />¢' <br />EMERGENCY RESPONSE <br />UCIL�G1 <br />2 3 4 <br />7 8 9jLc <br />RP SEARCH S I N R <br />DATE UNDERWAY <br />COMPLETED <br />PRELIMINARY ASSESSMENT <br />U ; C <br />DATE UNDERWAY <br />r <br />COMPLETED <br />REMEDIAL INVESTIGATION <br />C <br />DATE UNDERWAY" <br />� <br />COMPLETED <br />REMEDIAL ACTION <br />U v I C <br />DATE UNDERWAY <br />COMPLETED <br />POST REM ACT MONITORING <br />Y N U C <br />DATE UNDERWAY <br />COMPLETED <br />ENFORCEMENT ACT TAKEN <br />Y N <br />ENFORCEMENT TYPE 1 2 3 4 5 6 <br />DATE ACTION TAKEN <br />LUFT CONSIDERATION <br />1 2 H f S. C A R Y G 0 <br />.�_ <br />EXCAVATION STARTED <br />z I <br />CASE CLOSED Y R N <br />DATE CLOSED <br />REMEDIAL ACTION TAKEN <br />CD CB ED ET FP GT IT RS HU NA VS <br />Primary / Additional RESPONSIBLE PARTY <br />COMPANY NAME <br />s <br />PHONE <br />CONTACT NAME <br />PHONE <br />ADDRESS <br />CITY <br />STATE <br />ZIP <br />Additional RPIS Listed on REVERSE SIDE CONTAMINATED MFR INFO on REVERSE SIDE <br />EN 23 083(09/89)REVISED 11/90 89-20(IV)01/90 PILMFA <br />f <br />