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Y�'TH. DIVISION <br />SAN JDAOUIN QTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL <br />NON -LOP SITE MITIGATION/ASSESSMENT S�ITTAk•-10G;- • <br />SITE ADDRESS 2rD ` LEAD AGENCY <br />SITE CODE # T 3 PROG/EL MENT_ BILLING CODE S ASSIGNED TO �J <br />TITLE OF SUBMITTAL: r TYPE CODE <br />DATE RECEIVED D DATE SU9MITTAL O OT REQUEST OT REQUEST DATE <br />PERMIT FEE PDK #/CASH DATE REVIEW EE PD CK #/CASH DATE STAFF REVIEW DUE: <br />/ OT SCHEDULED: ,,,,,,,„,_/_/_ <br />y f/ y6Z OT CCMPLETED:� -4. <br />ACTION <br />DATE <br />ACTION <br />DATE <br />ACTION <br />DATE <br />ACKNOWLG/COMMTMNT LTR REOSTO <br />RECEIPT <br />INCOMPLETE/ADDTNL INFO REQSTD <br />SCHEDULE <br />SRP DUE <br />FOR SERVICE <br />ACKNOWLG/COMMTMNT LTR RECVD <br />RECEIVED <br />REVISION REOSTD <br />PR DUE <br />DUE <br />RWOCS COMMENTS <br />$53.00/ <br />REPORT REVIEW COMPLETE <br />PAR DUE <br />OTHER AGENCY APPROVAL <br />$60.00 <br />FILE/140 ACTION <br />FRP DUE <br />5 HOURS <br />ADDENDUM/ADDTNL INFO RECVD <br />DENIED <br />EACH <br />REVISION DUE <br />PERMIT ISSUED <br />W / B <br />SPECIAL PERMIT ISSUED <br />OTHER AGENCY DUE DATE <br />WORKPLAN REVIEW COMPLETE <br />N& <br />CCMMENT LTR SENT <br />HOUR <br />PROJECT COMPLETE/FINAL BILL <br />$265.00 <br />FOR AGENCY USE ONLY <br />SITE MITIGATION PROGRAM FEE <br />BASE <br />MINIMUM HOURS <br />MINIMLM <br />AMOUNT <br />RECEIVED <br />DATE <br />RECEIPT <br />AMOUNT <br />SCHEDULE <br />FEE <br />FOR SERVICE <br />FEE <br />RECEIVED <br />BY <br /># <br />DUE <br />UGT CORRECTIVE ACTION OVERSIGHT (CAP) <br />$53.00/ <br />WELL DESTRUCTION PERMIT APPLICATION <br />$60.00 <br />HOUR <br />5 HOURS <br />$265.00 <br />EACH <br />HAZARDOUS MATERIAL TRANSMISSION <br />$53.00/ <br />APPLC <br />PIPELINE ASSESSMENT OVERSIGHT <br />HOUR <br />5 HOURS <br />$265.00 <br />ENVIRONMENTAL ASSESSMENT WORKPLN/ <br />$53.00% <br />REVIEW AND INSPECTIONS <br />HOUR <br />3 HOURS <br />$159.00 <br />OTHER .GOVERNMENT AGENCY OVERSIGHT <br />$53.00/ <br />g� <br />�,,�/ <br />� <br />v, <br />1l <br />WORKPLAN/REVIEW AND INSPECTIONS <br />HOUR <br />3 HOURS <br />$159.00 <br />vt [ <br />�y <br />PERMIT ACTIVITY FEES <br />BASE <br />FEE <br />AMOUNT <br />RECEIVED <br />RECEIVED <br />BY <br />DATE <br />PERMIT <br /># <br />ISSUANCE <br />DATE <br />WELL/BORING PERMIT APPLICATION <br />(monitoring/extraction/vopor wells, <br />EE9.QQ <br />EACH <br />IJ r�, <br />soft borings, vapor surveys, etc.) <br />APPLC <br />WELL DESTRUCTION PERMIT APPLICATION <br />$60.00 <br />EACH <br />APPLC <br />EH 29 06 (BILFRMI2 revised 5/91) <br />