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SAN JOAQU#%mUNTY - PUBLIC HEALTH SERVICES/EHVIRONMENTA,,.rALTH DIVISION <br /> NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG Q�,� # - <br /> SITE ADDRESS <br /> _N <br /> SITE CODE # PROG/ELEMENT 2�...51_ BILLING CODE A SIGHED TO <br /> TITLE OF SUBMITTAL: TYPE CODE <br /> DATE RECEIVED DATE ON SUBMITTAL //",)xo�A OT REQUEST OT REQUEST DATE <br /> PERMIT FEE PD CK #/CASH DATE REVIEWFE[ PD CK #/CASH DATE STAFF REVIEW DUE: <br /> OT SCHEDULED: <br /> $ s2k ._Dv ���QJ �lj.zz q OT COMPLETED: <br /> ACTION DATE ACTION DATE ACTION DATE <br /> ACKNOWLG/COMMTMNT LTR REQSTD INCOMPLETE/ADDTNL INFO REQSTD SRP DUE <br /> ACKNOWLG/COMMTMNT ETR RECVD REVISION REQSTD PR DUE <br /> RWQCB COMMENTS REPORT REVIEW COMPLETE t PAR DUE <br /> OTHER AGENCY APPROVAL FILE/NO ACTION TZ l3 9 FRP DUE <br /> ADDENDUM/ADDTNL INFO RECVD DENIED REVISION 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 /> 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 8Y # DUE <br /> UGT CORRECTIVE ACTION OVERSIGHT (CAP) $53.00/ <br /> HOUR 5 HOURS $265.00 <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/ <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 /> soft borings, vapor surveys, etc.) APPLC <br /> WELL DESTRUCTION PERMIT APPLICATION $60.00 <br /> EACH <br /> APPLC <br /> EH 29 06 (BILFRMI2 revised 5/91) <br />