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SAN JOAQUIN L�Y • PUBLIC HEALTH SERVICES/ENVIRONMENTAL H6 DI VIS I,Q��7JyA <br /> /� <br /> NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG U ��llyyllll „f�[�_ <br /> SITE ADDRESS _ S ./�� ,�-�-�, q– IEAO AGENCY <br /> SITE CODE # 923 lJ/�1 PR�OG/EL•EYM(ENT 1 29.�,� BILLING CODE ASSIGNED TO I I_:–/— <br /> TITLE <br /> / <br /> TITLE OF SUBMITTAL: 9 z ® TYPE CODE U/ <br /> DATE RECEIVED /- L <br /> U, .r 9 2 DATE ON SUBMITTAL �/� �/ 2 OT REQUEST OT REQUEST DATE <br /> PERMIT FEE PO CK #/CASH DATE REVIEW FEE PD CK #/CASH DATE STAFF REVIEW DUE: <br /> $ OT SCHEDULED: <br /> $ 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 REOSTD PR DUE <br /> RWDCB COMMENTS REPORT REVIEW C PLETE PAR DUE <br /> OTHER AGENCY APPROVAL FILE/NO AC P 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 /> FOP AGENCY USE ONLY <br /> SITE MITIGATION PROGRAM FEE BASE MINIMUM HOURS MI NIMLFI AMOUNT RECEIVED DATE RECEIPT <br /> SCHEDULE AMOUNTFEE FOR SERVICE FEE RECEIVED BY <br /> # DUE <br /> UGT 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/ <br /> WORKPLAN/REVIEW AND INSPECTIONS HOUR 3 HOURS $159.00 <br /> BASE AMOUNT RECEIVED DATE PERMIT ISSUANCE <br /> PERMIT ACTIVITY FEES FEE RECEIVED BY <br /> # 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 />