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PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVI3a1 <br /> LOP PROGRAM - MFR INPUT FORM <br /> UPDATE 1-�.CJ/ El <br /> REVIEWED BY DATE ENTERED G)� By <br /> ADDITION: r\ EDIT: <br /> ENTERED LOP ? / SJ/PHS CONTACT [PRIORITY <br /> - U, r-/ <br /> NOR SENT LOC CODE DIST PROGRAM/ELEMENT CODET �� Ej <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SUBSTANCE #1 <br /> SITE CODE SOURCE OF FUNDSJ S / F FED EXEMPT Y / N PETROLEUM Y / N <br /> SITE NAME 'I z (sro c t r DATE REPORTED <br /> ADDRESS C/ / ✓f /4 I�_r DATE CONFIRMED <br /> rCA 21P MULTIPLE RP's Y / N <br /> SITE STATUS <br /> CASE TYPE CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> U SOD 1 2 3 4 5 T 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 1 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 H S C A R W G 0 <br /> EXCAVATION STARTED CASE CLOSED Y R H DATE CLOSED <br /> REMEDIAL ACTION TAKEN CD C9 ED ET FP GT IT RS HU NA VS <br /> Primary / Additional RESPONSIBLE PARTY <br /> COMPANY NAME PHONE <br /> CONTACT NAME ,:e PHONE <br /> ADDRESS )2 G ri ! dtrle- <br /> CITY / t tecc-/,c STATE 'Zia ZIP <br /> LEERP'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 />