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SAN kkmodNTY - PUBLIC HEALTH SERVI,CES/ENVIRONMENTAL HV>�1D <br /> NON40P SITE MIGATION/ASSESSMENT SUBMITTA <br /> TIL LOG <br /> SITE ADDRESS AD AGENCY <br /> SITE CODE # FROG/ELEMENT 2:2. ILLING CODE ASSIGNED TO <br /> TITLE OF SUBMITTAL: / <br /> HCODEE <br /> DATE RECEIVED C7 DATE ON SUBMITTAL !!OT REQUEST' OT REQUEST DATE <br /> !I <br /> PERMIT FEE PO CK #/ ASH DATE REVIEW FE PD CK #/CASH DATE( STAFF REVIEW DUE: <br /> / OT SCHEDULED: <br /> $ $� 0z) ! ?j b���j �0 /f3 OT COMPLETED: <br /> ii �k. IM <br /> ACTION DATE ACTION DAVE ACTION DATE <br /> I` ,I i� <br /> ACKNOWLG/COMMTMNT LTR REQSTD INCOMPLETE/ADDTNL INFO REQSTD �� fSRP DUE <br /> o- <br /> ACKNOWLG/COMMTMNT ETR RECVD REVISION REQSTD i PR DUE <br /> II i� it <br /> I RWQCB COMMENTS REPORT REVIEW COMPLETE , !PAR DUE <br /> C OTHER AGENCY APPROVAL FILE/NO ACTION ; i iFRP DUE <br /> ADDENDUM/ADDTNL INFO RECVD DENIED I� (REVISION DUE <br /> a ,il <br /> r <br /> PERMIT IMED W / B SPECIAL PERMIT ISSUED OTHER AGENCY DUE DATE <br /> I�. <br /> WORKPLAN REVIEW COMPLETE COMMENT LTR SENT I� PROJECT COMPLETE/FINAL BILL <br /> E FOR AGENCY USE'ONLY <br /> SITE MITIGATION PROGRAM FEE" BASE MINIMUM HOURS MINIMUM AMOUNT RECEIVED DATE RECEIPT AMOUNT <br /> SCHEDULE FEE FOR SERVICE !FEE RECEIVED it BY # DUE <br /> Ih UGT CORRECTIVE ACTION OVERSIGHT (CAP) $53,00/ <br /> HOUR 5 HOURS $265.00 I <br /> HAZARDOUS MATERIAL TRANSMISSION $53.00/ <br /> PIPELINE ASSESSMENT OVERSIGHT HOUR 5 HOURS $265.00 <br /> ENVIRONMENTAL ASSESSMENT WORKPLN/ $53.00/ <br /> REVIEW AND INSPECTIONS HOUR 3 HOURS $159.00 <br /> OTHER GOVERNMENT AGENCY OVERSIGHT $53.00/ k <br /> WORKPLAN/REVIEW AND INSPECTIONS HOUR 3 HOURS $159.00 <br /> II <br /> BASE AMOUNT. RECEIVED DATE PERMIT ISSUANCE <br /> PERMIT ACTIVITY FEES FEE RECEIVED BY # DATE <br /> WELL/BORING PERMIT APPLICATION $$9.00 <br /> (monitoring/extraction/vepor wells, EACH <br /> soil borings, vapor Surveys, etc.) APPLC <br /> A <br /> WELL DESTRUCTION PERMIT APPLICATION $60.00 <br /> EACH <br /> APPLC <br /> EH 29 06 (BILFRM12 revised 5/91) i <br /> A I� J <br />