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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION LOP PROGRAM - MFR INPUT FORM UPDATE �a-l�(p/� BY DATE ENTERED p%(p/9� BY ADDITION:_ EDIT: ENTERED LOP „ D,_I Q - U w v SJ/PHS CONTACT EMERGENCY RESPONSE PRIORITY J NOR SENT LOC CODE - DIST ZIP PROGRAM/ELEMENT CODE? MULTIPLE RP's SITE SPECIFIC QUARTERLY REPORT INFORMATION CONTRACTOR k 39000 SUBSTANCE O1 ., SITE CODE L SOURCE OF FUNDS . S / F FED EXEMPT Y / N PETROLEUM Y / N SITE NAME „ D,_I Q - U w v DATE REPORTED EMERGENCY RESPONSE ADDRESS��d J DATE CONFIRMED CITY - CA ZIP MULTIPLE RP's Y / N SITE STATUS CASE TYPE - CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE U S G D 1 •- 2 3 4 5 - 7 8 9 - RP SEARCH S I Nn - R DATE UNDERWAY - COMPLETED PRELIMINARY ASSESSMENT U C.: DATE UNDERWAY COMPLETED REMEDIAL INVESTIGATION U C DATE UNDERWAY COMPLETED REMEDIAL ACTION U I C DATE UNDERWAY COMPLETED POST REM ACT MONITORING Y N U C DATE UNDERWAY COMPLETED ENFORCEMENT ACT TAKEN Y N ENFORCEMENT TYPE 1 2 3 4 5 6 DATE ACTION TAKEN LUFT CONSIDERATION 1 2 3 .H S C A R N G 0 FA. EXCAVATION STARTED CASECLOSED Y R N DATE CLOSED REMEDIAL ACTION TAKEN CD CS ED ET FP GT IT RS HU ILA VS _Primary /„ _Additional RESPONSIBLE PARTY . COMPANY NAME `- ----• - - _ _ ----+-��""`-� PHONE CONTACT NAME-- ---.__ C. _ _p --.-----o-_ -,t PHONES ADDRESS CITY Com'-- �^" ,., STATE i"' ZIP 69 I� .Additional RP's Listed on REVERSE SIDE. -. - CONTAMINATED MFR INFO on REVERSE SIDE 89-20(IV)01/90 PILMFA EH 23 083(09/89)REVISED 11/90 -