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SAN JOAQUIN 6 T • PUBLIC HEALTH SERVICES/ENVIRONMENTAL +TH DIVISI # <br /> 2 (J' <br /> NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG # �J <br /> SITE ADDRESS LEAD AGENCY �ls <br /> SITE CODE # Q PROG/ELEMENT 22. BILLING CODE S ASSIGNED TO <br /> TITLE OF SUBMITTAL: TYPE CODE Q <br /> DATE RECEIVED DATE ON SUBMITTAL g OT REQUEST OT REQUEST DATE <br /> PERMIT FEE PD K #/CASH DATE REVIEW FEE PO CK #/CASH DATE STAFF REVIEW DUE: <br /> OT SCHEDULED: <br /> $ , V 2_�7 ?L g � "z OT COMPLETED: <br /> ACTION !' DATE ACTION / DATE ACTION DATE <br /> ACKNOWLG/COMMTMNT LTR REQSTD INCOMPLETE/ADDTNL INFO REQSTD SRP DUE <br /> ACKNOWLG/COMMTMNT LTR RECVD REVISION REQSTD PR DUE <br /> RWQCB COMMENTS REPORT REVIEW COMPLETE PAR DUE <br /> OTHER AGENCY APPROVAL FILE/NO ACTION FRP DUE <br /> ADDENDUM/ADDTNL INFO RECVD DENIED REVISION DUE <br /> PERMIT ISSUED W / a SPECIAL PERMIT ISSUED OTHER AGENCY DUE DATE <br /> WORKPLAN REVIEW COMPLETE CC14MENT 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 BY # DUE <br /> LOT 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/ ry „,� ,Q _ <br /> WORKPLAN/REVIEW AND INSPECTIONS HOUR 3 HOURS $159.00 1�jQ. fnfK •/M4I`,Z Zy2 0 <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 /> EH 29 06 (BILFRMI2 revised 5/91) <br />