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PHS SAN <br /> / �4OAQUIN COUNTY - ENVIRONMEN%4 HEALTH DIVISION <br /> PILOT PROGRAM - MFR INPUT FORM <br /> By DATE ENTERED <br /> _J_ BY <br /> ADDITION: _ T; DELETE:__ <br /> COMP 1C,�e r►�e. � 7 LOC CODE DIST 3j PROG/ELEMENT CODE3,S <br /> ENTERED PILOT / /3 / St� CONTAM MFR FILED <br /> / N PRIORITY <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR ,f 39000 SOURCE OF FUNDS S / F SUSSIWCE . <br /> SITE CODE I - / a FED EXEMPT Y /ON PETROLEUM Y N <br /> DATE REPORTED 6 J �g' /g DATE CONFIRMED <br /> 1 � /'S� /� CATEGORY � f S <br /> SITE NAME <br /> ADDRESS � <br /> CITY 42A& STATE CA ZIP <br /> sem. <br /> SITE STATUS <br /> CASE TYPE CONTRACT STATUS EMERGENCY RESPONSE <br /> U / S / G / D 1 2 3 4 5 6 7 8 <br /> RP SEARCH S / I / N / R DATE UNDERWAY <br /> 57 /a /gg COMPLETED //s- J�9 <br /> PRELIM ASSESSMNT U / C DATE UNDERWAY s /� / 4L� COMPLETED J J <br /> REMEDIAL INVEST U / C DATE UNDERWAY / / 0 COMPLETED f J <br /> REMEDIAL ACTION U / C DATE UNDERWAYJ __/ / COMPLETED f f <br /> DATE EXCAVATION STARTEDREMEDIAL ACTIONS TAKEN <br /> POST REMEDIAL ACTION MONITORING Y / N / U / C <br /> POST REMED ACT MONITOR DATE UNDERWAY / / COMPLETED / f <br /> ENFORCE ACT TAKEN Y / N DATE UNDERWAY / / COMPLETED / f <br /> ENFORCEMENT ACTION TYPE_T_ 1 J 2 / 3 / 4 / 5 / 5 <br /> CASE CLOSED Y / R / H DATE CASE CLOSED J / <br /> RESPONSIBLE PARTY <br /> COMPANY NAME PHONE a0 d <br /> W w <br /> CONTACT NAME PHONE <br /> ADDRESS <br /> CITY STATEC� ZIP 9��oz <br /> EH 23 083 (6/89) 89-20k.�V) 5/89 PILMFR <br />