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yN <br /> SAN JOAQUIN COLM - PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DTVII � . <br /> NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG `4- <br /> SITE .ADDRESS 43 S S LEAD AGENCY <br /> SITE CODE # GJPROC/ELEMENT 2�.�J� BILLING CODE S ASS <br /> 2 7IGNED TO <br /> v <br /> TITLE OF SUBMITTAL: / / TYPE CODE / <br /> DATE RECEIVED / DATE ON SU ITTAL / / OT REQUEST OT REQUEST DATE <br /> PERMIT FEE PD EK #//CASH DATE REVIEW FSE PO' CK #/CASH DATE STAFF REVIEW DUE: <br /> OT SCHEDULED: <br /> S ; OT COMPLETED: <br /> ACTION DATE ACTION DATE ACTION DATE <br /> ACKNOWLG/COMMTMNT LTR REOSTD INCCMPLETE/AODTNL INFO REOSTD SRP DUE <br /> ACKNCWLG/COMMTMNT LTR RECVD REVISION REQSTD PR DUE <br /> RWOCS COMMENTS REPORT REVIEW COMPLETE PAR DUE <br /> OTHER AGENCY APPROVAL FILE/40 ACTION FRP DUE <br /> ADDENDUM/ADDTNL INFO RECVD DENIED REVISION DUE <br /> PERMIT ISSUED W / B SPECIAL PERMIT ISSUED OTHER AGENCY DUE DATE <br /> ORKPLAN REVIEW COMPLETE COMMENT 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 /> UGT CORRECTIVE ACTION OVERSIGHT (CAP) 553.00/ <br /> HOUR 5 HOURS $265.00 <br /> HAZARDOUS MATERIAL TRANSMISSION 853.00/ <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/ <br /> WORKPLAN/REVIEW AND INSPECTIONS HOUR 3 HOURS $159.00 <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 /> it borings, vapor surveys, etc.) APPLC <br /> WELL DESTRUCTION PERMIT APPLICATION $60.00 <br /> EACH <br /> APP LC <br /> EH 29 06 (BILFRMI2 revised 5/91) <br />