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SAN JOAQUIN * - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HDIVISION <br /> NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG 7 <br /> SITE ADDRESS Z LEAD AGENCY <br /> SITE CODE # O'3 PROG/ELEMENT 2g.�_ BILLING CODE. ASSIGNED TO <br /> TITLE OF SUBMITTAL: TYPE CODE <br /> DATE RECEIVED ( 'J DA?E ON SUBMITTAL / / OT REQUEST OT REQUEST DATE �J <br /> PERMIT FEE PD CK #/CASH DATE REVIEW FEE Po CK #/CASH DATE STAFF REVIEW DUE: _//+_/_ <br /> OT SCHEDULED: <br /> $ $ OT COMPLETED: <br /> ACTION DATE ACTION DATE T ACTION DATE <br /> ACKNOWLG/COMMTMNT LTR REOSTD INCOMPLETE/ADDTNL INFO REQSTD SRP DUE <br /> ACKNOWLG/COMMTMNT LTR RECVD REVISION REOSTD PR DUE <br /> RWQCB COMMENTS REPORT REVIEW COMPLETE DUE <br /> OTHER AGENCY APPROVAL FILE/NO ACTION �l 2.� I� FRP D E <br /> ADDENDUM/ADDTNL INFO RECVD DENIED SION DUE <br /> PERMIT ISSUED W / B SPECIAL PERMIT ISSUED OTHER AGENCY DUE DATE <br /> WORKPLAN REVIEW COMPLETE COMMENT LTR SENT PROJECT COMPLETE/FINAL BILL <br /> FOS ,!GFNCY USE ONLY <br /> SITE MITIGATION PROGRAM FEE BASE MINIMUM HOURS MINIMUM AMOUNT RECEIVED DATE RECEIPT AMOUNT <br /> SCHEDULE FEE FOR SERVICE FEE RECEIVI'O SY # DUE <br /> UGT CORRECTIVE ACTION OVERSIGHT (CAP) $53.00/ <br /> HOUR 5 HOURS $265.0O <br /> HAZARDOUS MATERIAL TRANSMISSION $53.00/ <br /> PIPELINE ASSESSMENT OVERSIGHT HOUR 5 HOURS $265.00 <br /> ENVIRONMENTAL ASSESSMENT WORKPLN/ $53.00/ I <br /> REVIEW AND INSPECTIONS HOUR 3 HOURS $159.00 <br /> OTHER GOVERNMENT AGENCY OVERSIGHT $53.00/ <br /> WORKPLAN/REVIEW AND INSPECTIONS HOUR 3 HOURS $159.00 <br /> BASE AMOUNT RECEIVED DATE PERMIT ISSUANCE <br /> PERMIT ACTIVITY FEES FEE RECEIVED BY # DATE <br /> WELL/BORING PERMIT APPLICATION $89.00 <br /> (monitoring/extraction/vapor Wells, EACH <br /> soil borings, vapor surveys, etc.) APPLC <br /> WELL DESTRUCTION PERMIT APPLICATION $60.00 <br /> EACH <br /> APPLC <br /> EN 29 06 (BILFRMI2 revised 5/91) <br />