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SAN JOAQUIN ITY - PUBLIC HEALTH SERVICES/ENVi !!MENTAL TH DIVISI r� <br /> NON-LOP SITE MITiGAT10N/ASSESSMENT SUBMI TAL LOG # .� <br /> SITE ADDRESS / AZI xv I LEAD AGENCY <br /> SITE CODE # 5( PROG%ELEMENT 2BILLING CODE 5 ASSIGNED TO <br /> vv <br /> TITLE OF SUBMITTAL: �� TYPE CODE <br /> 'P r <br /> DATE RECEIVED 2 Z DATE ON SUB TAE OT REQUESTJOT REQUEST DATE <br /> IM <br /> PERMIT FEE PD CK #//CASH jDATE REVIEW! fEE CK #/CASH � TE � STAFF REVIEW DUE: <br /> OT SCHEDULED: <br /> $ `� >vv / �S�r� �Z�p`� yl} _OT COMPLETED: <br /> r0 € <br /> ACTION DATE ACTION DATE h ACTION DATE <br /> ACKNOWLG/COMMTMNT LTR REOSTD INCOMPLETE/ADDTNL INFO REQSTD SRP DUE <br /> ACKNOWLG/COMMTMNT LTR RECVD REVISION REQSTD I{ PR DUE <br /> ff ;h <br /> RWQC$ COMMENTS REPORT REVIEW COMPLETE I� PAR DUE <br /> h <br /> OTHER AGENCY APPROVAL FILE/NO ACTION { FRP DUE <br /> ADDENDUM/ADDTNL INFO RECVD DENIED Il REVISION DUE <br /> PERMIT ISSUED W <br /> / B SPECIAL PERMIT ISSUED I OTHER AGENCY DUE DATE <br /> WORKPLAN REVIEW COMPLETE COMMENT LTR 5ENT �{ PROJECT COMPLETE/FINAL BILL <br /> FOR AGENCY iISE ONLY i a <br /> SITE MITIGATION PROGRAM FEE" BASE MINIMUM HOURS MINIMUM AMOUNT RECEIVED DATE RECEIPT AMOUNT <br /> SCHEDULE FEE FOR SERVICE FETE RECEIVED BY ## DUE <br /> q <br /> UGT CORRECTIVE ACTION OVERSIGHT (CAP) $53.00/ Ir <br /> HOUR 5 HOURS $265.00 !} <br /> HAZARDOUS MATERIAL TRANSMISSION $53.00/ <br /> I� k <br /> PIPELINE ASSESSMENT OVERSIGHT HOUR 5 HOURS $265.00 <br /> ENVIRONMENTAL ASSESSMENT WORKPLN/ $53.00/ 4` <br /> REVIEW AND INSPECTIONS HOUR 3 HOURS $159.00 <br /> I <br /> OTHER GOVERNMENT AGENCY OVERSIGHT 553.00/ <br /> WORKPLAN/REVIEW AND INSPECTIONS HOUR 3 HOURS $159.00 <br /> rt �M <br /> BASE <br /> AMOUNT. RECEIVED DATE PERMIT ISSUANCE <br /> . <br /> PERMIT ACTIVITY FEES FEE RECrEIVED BY # DATE <br /> i <br /> WELL/BORING PERMIT APPLICATION $89,00 <br /> (monitoring/extrOCtiOn/Vapor ueLLs, EACH !, <br /> soft borings, vapor Surveys, etc.) APPLC <br /> 4 <br /> WELL DESTRUCTION PERMIT APPLICATION $50.00 s� <br /> EACH <br /> i <br /> APPLC------------- <br /> i <br /> ii <br /> EH 29 06 (BILFRM12 revised 5/91) <br />