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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION <br /> PILOT PROGRAM - MFR INPUT FORM <br /> tiP!lATE j 0 uirk�� <br /> REVIEWED BY <br /> 4 DATE ENTERED BY <br /> ADDITION: ,_ EDIT:,__ <br /> ENTERED PILOT SJ-PHS CONTACT <br /> i� SWEEPS A FPRIORITYJ <br /> COMP 0 LOC CODE DIST 3PROG/ELEMENT CODE e�3 / <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR * 39000 FsOURCE OF FUNDS S / F SUBSTANCE �' 3 <br /> SITE CODE r FED EXEMPT Y / N PETROLEUM Y / N <br /> SITE NAME /n <br /> DATE REPORTED <br /> ADDRESS PATE CONFIRME <br /> CITY �� <br /> G1 :ZIP CATEGORY / g <br /> SITE STATUS <br /> CASE TYPE CONTRACT STATUS EMERGENCY RESPONSE <br /> U N G D 1 2 3 4 5 7 8 9 <br /> RP SEARCHC9 1 N R DATE UNDERWAYCOMPLETED �' Z <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 /> LUFT CONSIDERATION 1 2 3 R Y G 0 <br /> EXCAVATION STARTED < � CASE CLOSED C3> R H DATE CLOSED 1 <br /> REMEDIAL ACTION TAKEN CD CB ED E FP GT IT RS HU HA VS <br /> RESPONSIBLE PARTY <br /> COMPANY NATE PHONE <br /> CONTACT NATE PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> EH 23 083(09/89)REVISED 01/90 <br />