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PHS/SAN*QUIN COUNTY - ENVIRONMENTAL HEALTH DIVISION* <br /> LOP PROGRAM - MFR INPUT FORM <br /> UPDATE � BY REVIEWED BY <br /> DATE ENTERED BY <br /> 9- � <br /> ADDITION: EDIT: <br /> PRIORITY <br /> ENTERED LOP EE]jSj/pjHSCONTACET <br /> NOR SENT DIST PROGRAM/ELEMENT CODE 27 5 <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SUBSTANCE #1 <br /> 2 3 <br /> SITE CODE Ifs 7 <br /> J SOURCE OF FUNDS S / F FED EXEMPT Y / PETROLEUM OY / N <br /> ✓✓ DATE REPORTED <br /> SITE NAME <br /> DATE CONFIRMED <br /> ADDRESS <br /> CA ZIP MULTIPLE RP's Y / N <br /> CITY <br /> SITE STATUS <br /> RINVESTIGATION <br /> CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> 1 2 3 4 5 6 7 8 <br /> ! NR DATE UNDERWAY COMPLETED <br /> MENTUC DATE UNDERWAY COMPLETED <br /> TION <br /> U C DATE UNDERWAY COMPLETED <br /> REMEDIAL ACTION U I C <br /> DATE UNDERWAY COMPLETED <br /> POST REM ACT MONITORING Y N U C <br /> DATE UNDERWAY COMPLETED <br /> ENFORCEMENT ACT TAKEN Y N ENFORCEMENT TYPE 1 <br /> 2 3 4 5 6 DATE ACTION TAKEN <br /> LUFT CONSIDERATION <br /> 1 2 3 H S C A R W G 0 <br /> EXCAVATION STARTED <br /> CASE CLOSED Y R C L DATE CLOSED <br /> REMEDIAL ACTION TAKEN CD CB ED ET FP GT IT RS HU NA VS VE NT OT UK <br /> Primary / Additional RESPONSIBLE PARTY <br /> PHONE <br /> COMPANY NAME �T1JLL�-/L'l(_J <br /> C <br /> CONTACT NAME PHONE <br /> U <br /> ADDRESS boo <br /> C4 76k _ <br /> Vl/ STATE n ZIP <br /> CITY ,J <br /> Additional RP's listed on REVERSE SIDE <br /> CONTAMINATED MFR INFO on REVERSE SIDE <br /> 89-20(IV)01/90 PILMFA <br /> EH 23 083(09/89)REVISED 8/92 <br />