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PH3f JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIY�N <br /> CAP PROGRAM - MFR INPUT FORM 4 <br /> UPDATE Z'7 G�, BY REVIEWED BY DATE ENTERED x Q BY <br /> I <br /> ADDITION• EDIT• <br /> SITE COOE �b� PROGRAM/ELEMENT ��� �_ _ LOC CODE 7t DIST 132,0 <br /> PRIORITY <br /> ENTERED CAP 67 �rl SJ/EH CONTACT yok,- INITIAL REVIEW FEE PD -Z4 moa <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION `7 <br /> C <br /> SUBSTANCE #1 KOOG(�I�j 2 PETROLEUM Y / N } <br /> i <br /> FED EXEMPTdI <br /> Y ' N LEAD AGENCY w�` pS �� <br /> .^ <br /> SITE NAME / DATE REPORTED <br /> ADDRESS4/o L DATE CONFIRMED <br /> C <br /> CITY CA ZIP MULTIPLE RP's Y lll/ <br /> �I-7 <br /> SITE STATUS i <br /> CASE TYPE SITE STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> U S G D ' 1 2 ., 4 5 7 8 9 <br /> RP SEARCH 1 N R DATE UNDERWAY 4?4,'1 /q/ COMPLETED <br /> PRELIMINARY ASSESSMENT U C DATE UNDERWAY 7i Q COMPLETED <br /> REMEDIAL INVESTIGATION U C DATE UNDERWAY !L 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 GATE ACTION TAKEN <br /> LUFT CONSIDERATION 1 2 3 H S C A R W G 0 <br /> EXCAVATION STARTED 1 CASE CLOSED Y R H DATE CLOSED <br /> REMEDIAL ACTION TAKEN 7 CD CB ED ET FP GT IT RS HU NA VS <br /> Primary / Additional RESPONSIBLE PARTY <br /> COMPANY NAME / ,�A �L14k� 7 ! PHONE <br /> CONTACT NAME LJ !v, PHONE <br /> ADDRESS S-vo 6 <br /> CITY �7I � STATE CA ZIP <br /> Additional RP's listed on REVERSE SIDE CONTAMINATED MFR INFO on REVERSE SIDE <br /> EH 23 (03191)IV CAPMFR " '" <br />