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SITE CODE # <br />SITE ADDRESS <br />) <br />PROG/ELEMENT BILLING CODE <br />SAN JOAQUIN ITY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL ,TH DIVISION <br />NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG # <br />LEAD AGENCY <br />ASSIGNED TO r <br />0,11 TITLE OF SUBMITTAL: TYPE CCOE <br />DATE RECEIVED -51/2-4 DATE ON SUBMITTAL OT REQUEST OT REQUEST DATE <br />PERMIT FEE PD CK #/CASH DATE REVIEW FEE PD CK #/CASH DATE STAFF REVIEW DUE: / / <br />OT SCHEDULED: _/_/_ <br />$ r-o $ o9V0F3S- OT COMPLETED: / / <br />ACTION DATE ACTION DATE ACTION DATE <br />ACKNOWLG/COMMTMNT LTR REOSTD INCOMPLETE/ADDTNL INFO REOSTD SRP DUE <br />ACKNOWLG/COMMTMNT LTR RECVD REVISION REQSTD PR DUE <br />RWOCB COMMENTS <br />, <br />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 / 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 <br />SCHEDULE <br />BASE <br />FEE <br />---------- <br />MINIMUM HOURS <br />FOR SERVICE <br />MINIMUM <br />FEE <br />AMOUNT <br />RECEIVED <br />RECEIVED <br />BY <br />DATE RECEIPT <br /># <br />AMOUNT <br />DUE <br />UGT CORRECTIVE ACTION OVERSIGHT (CAP) $53.00/ <br />HOUR 5 HOURS $265.00 <br />HAZARDOUS MATERIAL TRANSMISSION <br />PIPELINE ASSESSMENT OVERSIGHT <br />$53.00/ <br />HOUR 5 HOURS $265.00 <br />ENVIRONMENTAL ASSESSMENT WORKPLN/ <br />REVIEW AND INSPECTIONS <br />$53.00/ <br />HOUR 3 HOURS /7- <br />I <br />59.00 <br />OTHER GOVERNMENT AGENCY OVERSIGHT <br />WORKPLAN/REVIEW AND INSPECTIONS <br />$53.00/ <br />HOUR 3 HOURS $159.00 <br />PERMIT ACTIVITY FEES <br />BASE <br />FEE <br />AMOUNT <br />RECEIVED <br />RECEIVED <br />BY <br />DATE PERMIT <br /># <br />ISSUANCE <br />DATE <br />WELL/BORING PERMIT APPLICATION <br />(monitoring/extraction/vapor wells, <br />soil borings, vapor surveys, etc.) <br />$89.00 <br />EACH <br />APPLC <br />WELL DESTRUCTION PERMIT APPLICATION $60.00 <br />EACH <br />APPLC <br />(BILFRM12 revised 5/91) EH 29 06