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PHS` 1 JOAQUIN COUNTY - ENVIRONMENTAL HEALTH DIVi <br /> } LOP PROGRAM - MFR INPUT FORM <br /> UPDATE 9� BY REVIEWED BY DATE ENTERED ,7 BY <br /> ADDITION• EDIT: <br /> i <br /> ENTERED PILOT SJ/PHS CONTACT SWEEPS PRIORITY <br /> NOR SENT LOC CODE DIST PROGRAM/ELEMENT CODE <br /> SITE SPECIFIC QUARTERLY REPORT INFORMATION <br /> CONTRACTOR # 39000 SUBSTANCE #1 5 <br /> SITE CODE !O '� SOURCE OF FUNDS S % / F FED EXEMPT Y / N PETROLEUM Y / N <br /> 4 <br /> SITE NAME M C ��s S �U DATE REPORTED <br /> ADDRESS Z 3 ?� Ali DATE CONFIRMED <br /> CITY CA ZIP MULTIPLE RP's Y / fN <br /> SITE STATUS <br /> CASE TYPE CONTRACT STATUS w STATUS CHANGE DATE EMERGENCY RESPONSE <br /> U S G D 1 2 3 4 5 r 7 8 9 <br /> RP SEARCH S 1 N R DATE UNDERWAY COMPLETED <br /> PRELIMINARY ASSESSMENT U C DATE UNDERWAY COMPLETED <br /> REMEDIAL INVESTIGATION U DATE UNDERWAY w COMPLETED <br /> REMEDIAL ACTION U 1 C DATE UNDERWAY y 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 /> LOFT CONSIDERATION 1 2 3 H S C A R W G 0 <br /> EXCAVATION STARTED CASE CLOSED Y R H DATE CLOSED <br /> REMEDIAL ACTION TAKENCD CB ED ET FP GTt IT RS HU NA VS <br /> Primary Additionat RESPONSIBLE PARTY <br /> COMPANY NAME � (/} //�� r ,PHONE <br /> del <br /> If CONTACT NAME I PHONE <br /> ADDRESS �Oad I�l�. �L.Q_ Q CYT` Z,00U <br /> F <br /> \ <br /> CITY <br /> i �•{� v STATE ZIP <br /> Additional RP'S listed on REVERSE SIDE CONTAMINATED MFR INFO on REVERSE SIDE <br /> EH 23 083(09189)REVISED 11/90 T 89-20(IV)01/90 PILMFA <br />