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PHSP.9N JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVI-: <br /> LOP PROGRAM - MFR INPUT FORM <br /> UPDATE BY REVIEWED BY DATE ENTERED l BY <br /> v' <br /> ADDITION• vle EDIT• <br /> ENTERED LOP SJ/PHS CONTACT PRIORITY <br /> NOR SENT LOC CODE DIST JPROGRAM/ELEMENT CODE h�J <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION •J c. <br /> CONTRACTOR # 39000 SUBSTANCE #1 <br /> SITE CODE li SOURCE OF FUNDS S / F FED EXEMPT Y / N PETROLEUM Y / N <br /> SITE NAME I ! DATE REPORTED <br /> ADDRESS I A I l•Gl DATE CONFIRMED <br /> CITY CA ZIP I 1:7LT1PLE RP's y / <br /> SITE STATUS •J vU <br /> CASE TYPE CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> U S D 1 2 3 4 O5 iP + <br /> RP SEARCH S I N R DATE UNDERWAY COMPLETED <br /> PREL1MIUARY ASSESSPUT U CO DATE UNDERWAY COMPLETED <br /> REI'EDIAL INVESTIGATIC?1 (q) C DATE UNDERWAY n 2 COMPLETED (�7 <br /> REMEDIAL ACTIOU� U OI C DATE UNDERWAY ( v�n7/9 COMPLETED COMPLETED <br /> POST REM ACT MONITORING Y N U C DATE =WAY v7 J COMPLETED <br /> ENf 2CEP'E1IT ACT TACEH N 9NFCRCErlHT TYPE/ 2 3 4 5 6 DATE ACTIC11 TAXEUi <br /> LLFT CONSIDERATION' 1 2 0 H S © 0 D W 0 <br /> _7CAVATIOU STARIED 2,a r(,� CASE CLOSED Y R H DATE CLOSED ` <br /> REMEDIAL ACTION TAI(EH i CD CB ED t FP GT IT RS HU HA VS <br /> V Primary / Additional RESPONSIBLE PARTY <br /> COMPANY NAME C �� S . \ PHC:�E ` . 9,p�� ' '7L/ <br /> CCUTACT NAME� J C�tv /v PHONE I <br /> L <br /> ADDRESS Y <br /> CITY 5 k� 'C STATE CA- ZIP <br /> _j. <br /> Additional RP's listed on REVERSE SIDE y CONTAMINATED MFR INFO on REVERSE SIDE x <br /> EH 23 083(09/89)REVISED 11/90 l 89-20(IV)01/90/PIILMFA <br />