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PHS, JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVI`� <br /> LOP PROGRAM - MFR INPUT FORM <br /> UPDATE 3 Q•(� I BY]_'�- REVIEWED BY DATE ENTERED BY <br /> ADDITION• EDIT• y� <br /> ENTERED PILOT) R u SJ/PHS CONTACT � � <br /> • S �a&j:-7LFSWEEPS # ua>q PRIORITY <br /> NOR SENT I 1_l V LOC CODE Q DIST f-960AM/EL+EMENT CODE 2e Z (� <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SUBSTANCE #1 <br /> SITECODE , 'Jq SOURCE OF FUNDS U / F FED EXEMPT Y / a PETROLEUM © / N <br /> SITE NAME DATE REPORTED x <br /> ADDRESS c I ru5y DATE CONFIRMED <br /> CITY �y�+ �J�_ CA ZIP MULTIPLE RP's Y / <br /> SITE STATUS cam/ <br /> CASE TYPE CONTRACT STATUS ,STATUS CHANGE DATE 4 EMERGENCY RESPONSE <br /> U SD 1 2 3 4 5 7 8 9 `1 . ?)Q•q � <br /> RP SEARCH V I N R DATE UNDERWAY 4 I ' (O q o COMPLETED �, { Q Ci <br /> PRELIMINARY ASSESSMENT C DATE UNDERWAY I q0 COMPLETED <br /> REMEDIAL INVESTIGATION U y,G DATE UNDERWAY 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 w) ENFORCEMENT TYPE 1 2 3 4 5 6 DATE ACTION TAKEN <br /> LUFT CONSIDERATION 1 2 3 H S C A R W 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 Slg PHONE Q,1S g42 -7(o-2,6 <br /> CONTACT NAME ( � PHONE 4(!J n.1. -7 (_ <br /> ADDRESS P /�/� • ��(� <br /> CITY � I�nrs STATE Cp► 21P ��� <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 />