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11 y <br /> PHS/SAN JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIT,=S <br /> / LOP PROGRAM - MFR INPUT FORM <br /> UPDATE ;/ "/�� BY REVIEWED BY DATE ENTERED / s q B <br /> 111 ADDITION: EDIT: Y' / <br /> i <br /> ENTERED PILOT I J SJ/PHS CONTACT � N Q SWEEPS # I /) PRIORITY <br /> / l / <br /> NOR SENT LOC CODE DIST PROGRAM/ELEMENT CODE 2y _�- <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SUBSTANCE #1 2 5 <br /> SITE CODE (f SOURCE OF FUNDS S / / FJ FED EXEMPT Y / N PETROLEUM Y \ / N <br /> l✓ � <br /> SITE NAME /'/ DATE REPORTED 1. 7 <br /> ADDRESS /�/ yI � � DATE CONFIRMED <br /> CITY \2) , / r� CA ZIP '� MULTIPLE RP's Y / N <br /> SITE STATUS <br /> CASE TYPE CONTRACT STATUS STATUS CHANGE DATE EMERGENCY RESPONSE <br /> U S G D 1 2 �3 4 5 7 8 9 <br /> RP SEARCH I N R DATE UNDERWAY J �i COMPLETED CZ/ <br /> PRELIMINARY ASSESSMENT U � C DATE UNDERWAY / ��// COMPLETED <br /> � <br /> REMEDIAL INVESTIGATION U Ic DATE UNDERWAY 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 DATE ACTION TAKEN <br /> LUFT CONSIDERATION 1 3 rR > (G,) 0 <br /> EXCAVATION STARTED CASE CLOSED Y R H DATE CLOSED <br /> REMEDIAL ACTION TAKEN CD CB ED ET FP GT IT RS HU NA VS <br /> "'Primary / Additional RESPONSIBLE PARTY / <br /> COMPANY NAME PHONE ( Z D �/���- <br /> ✓Z.D C <br /> CONTACT NAME PHONE <br /> dhJ <br /> ADDRESS <br /> CITY STATE ( ZIP FeF r-7 O3 <br /> Additional RP's listed on REVERSE ST^= CONTAMINATED MFR INFO on REVERSE SIDE <br /> EH 23 083(09/89)REVISED 11/90 t 89-20(IV)01/90 PILMFA <br />