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r <br /> PHS/S� JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVI�1 <br /> LOP PROGRAM - MFR INPUT FORM <br /> EE: <br /> G� a� gY -YIi)� REVIEIIED BY <br /> DATE ENTERED By <br /> ADDITION: EDIT:__z <br /> ENTERED LOP SJ/PHS CONTACT <br /> PRIORITY <br /> NOR SENT LOC CODE DIST PROGRAM/ELEMENTI-E <br /> CODE �'f <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SUBSTANCE #1 <br /> SITE CODE 'Q SOURCE OF FUNDS S / F FED EXEMPT Y / N PETROLEUM Y / N <br /> SITE NAME A DATE REPORTED <br /> ADDRESS �! i ; �lJ DATE CONFIRMED <br /> ICA I ZIP MULTIPLE RP's Y / N <br /> u ` SITE STATUS <br /> CASE TYPE CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> U S G D 1 2 3 4 5 7 8 9 <br /> RP SEARCH S I N R DATE UNDERWAY COMPLETED <br /> PRELIMINARY ASSESSMENT U C DATE UNDERWAY COMPLETED <br /> REMEDIAL INVESTIGATION U C 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 N ENFORCEMENT TYPE 1 2 3 4 5 6 DATE ACTION TAKEN <br /> LOFT 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 CS ED ET FP GT 1T RS HU NA VS <br /> Primary / Additional RESPONSIBLE PARTY <br /> COMPANY NAME PHONE <br /> CONTACT NAME PHONE <br /> ADDRESS `E <br /> CITY STATE ZIP <br /> Additionat 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 />