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STA;E OF CALIFORNIA-THE RESOURCES AGENCY <br /> DEPARTMENT OF FISH AND GAM253903 <br /> ENVIRONMENTAL FILING FEE CA ECEIPT <br /> DFG 753.5a(M3) LI-11 ,j nn <br /> Lead Agency: 0 Date: ;� <br /> County/State Agency of Filing: t�"1 Document <br /> Project Title: 1 <br /> Project Applicant Name: Phone Number: <br /> Project Applicant Address: <br /> Project Applicant(check appropriate box): Local Public Agenc School District Other Special District <br /> State Agency Private Entity <br /> CHECK APPLICABLE FEES: <br /> ( ) Environmental Impact Report $850.00 $ <br /> ( } Negative Declaration $1,250.00 $ <br /> ( ) Application Fee Water Diversion(State Water Resources Control Board Only) $850.00 $ <br /> ( ) Projects Subject to Certified Regulatory Programs $850.00 $ <br /> ( ) Administrative Fee $25.00 $ <br /> (tool Project that is exempt from fees <br /> TOTAL RECEIVED $ <br /> Signature and title of person receiving payment: <br /> WHITE-PROJECT APPLICANT YELLO SB PINK-LEVAGENCY GOLDENROD-STATE AGENCY OF FILING <br />