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SAM J(lAOUi JNTY – PUBLIC HEATH REID <br /> SEAVICESJENVIRQNMENTAI TH DIVISION <br /> SITE MITIGATION/ASSESSMENT SUBMITTAL LUG 17Y11 y gQ _ l g <br /> SITE NAMlE <br /> OTHER LEAD AGENC — <br /> ADDRESS AGENCY <br /> G[% GENCY CONTACT <br /> CITY � Q—Ez <br /> . i <br /> TIP PHONE w/AREA"CD <br /> CONSULTANT COMPANY — �--- _ <br /> :CONTACT <br /> OTHER CONTACT NAME or INFORMATI ; <br /> I <br /> UGT SITE 23. ASSESS—DHS / RWOCB 22. ENVIRON ASSE 22.49 PILO 23 FUND SOURF TASK # <br /> F <br /> SWEEPS #/SITE CODE # l'k77� DIST Imo/ LOC CD <br /> ASSIGNED TOQ <br /> -- J <br /> TITLE OF SUBMITTAL: -- <br /> 'M i <br /> ih <br /> DATE RECEIVED DATE OF SUBMITT , <br /> `BILLING FORM INITIATED 1 I OT REOST I /_ <br /> TYPE OF SUBMITTAL (PILOT) COD TYPE OF SUBMITTAL (OTHER) COD FEE PD CK #JCRSI DATE <br /> RE-EXCAV/SOIL CONTAMINATION WORKPLAN (SM) I PERMIT ,APPLICATION 10 1 <br /> SOIL CONTAMINATION REPORT/REMEDIATION PLAN (SRP) 2 WORKPLAN" for PERMIT ACTIVITY 11 <br /> PRELIMINARY REPORT (PR) 3 ASSESS REPORT 13 , <br /> 0 �p <br /> PR/with ADDTL ASSESS PROPOSAL4 ASSESS REPORT/with WORKPLAN 14 <br /> PROBLEM ASSESSMENT REPORT IPAR) 5 ORTLY/MONITORING REPORT 15 p <br /> ,$ i <br /> PAR/with REMEDIAL ACTION PROPOSAL' 6 OTHER WRKPLAN w/o PERMIT ACTIVITY 16 <br /> i <br /> ADDITIONAL ASSESSMENT PROPOSAL <br /> FINAL REMEDIATION PLAN (FRP) g { <br /> iI <br /> DRILY RENAT/POST RIM! MONITOR <br /> STAFF REVIEW DUE —/—/— OT SCHEDULED ! % OT COMPLETED <br /> ACTION DATE ACTION BATE ACTION i DATE <br /> ACKNOWL6/COMMTMNT LTR REOSTO INCOMPLETE/ADDTNL INFOiREOSTI SRP DUE <br /> 90WWLGJCDMMTKNT LTR RECVD REVISION REOSTD ' PR DUE ,p <br /> Ob <br /> RWDCB COMMENTS 312-gl,?7 REVIEW COMPLETE if PAR DUE �5 <br /> y! <br /> OTHER AGENCY APPROVAL FILE/NO ACTION ��/ U FRP DUE <br /> ADDENDUM/ADDTNL INFO RECV I <br /> D DENIED REVISION DUE <br /> PERMIT ISSUEDAz <br /> SPECIAL PERMIT,ISSUED ! I <br /> OTHER AGENCY DUE BATE <br /> ;R <br /> WORKPLAN APPROVED COMMENT LTR SENT Is BILLING FORM SUBMITTED ' <br /> EH 23-117 89-57(IV)12/99 PLNLOG <br />