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SAN JOAQUIN .ATY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL _TH DIVISION <br /> SITE MITIGATION SUBMITTAL <br /> DO NOT WRITE IN THIS AREA-AGENCY USE ONLY /��Q� SUBMITTAL LOG NUMBER <br /> GT SITE 23._1ASSESS- DHS / RWQCB 22.J2 1 <br /> NVIRON ASSESS 22.48 ITHER (PROG/ELEMENT PILOT PROGRAM <br /> EEPS #/SITE CODE # �/„ COMPUTER # DATES OF SERVICE FROM _/_/_ TO <br /> LOC CODE 1 DZ DISTRICT I 3,-)_+SIGNED TO �2_ N <br /> YPE OF SUBMITTAL or / TYPE <br /> ESCRIPTION OF SERVICE CODE <br /> DATE RECEIVED / / DATE OF SUBMITTAL / / T REQUESTED I IDATE OT REQUESTED <br /> EERMITEE PD �{J K#/CASH �� ATE / EVIEW FEE PO /�� K#/CASH �j�S// ATE <br /> STAFF REVIEW DUE ' /_/_ OT SCHEDULED _/_/_ OT COMPLETED_/_O/-(O <br /> ACTION DATE ACTION DATE ACTION DATE <br /> CKNOWLG/COMMTMNT LTR REQSTD INCCMPLETE/ADDTNL INFO REQSTD SRP DUE <br /> CKNOWLG/COMMTMNT LTR RECVD REVISION REQSTD DR DUE <br /> WQCS COMMENTS 2 / EVIEW COMPLETE AR DUE <br /> THER AGENCY APPROVAL Z �! / FILE/NO ACTION RP DUE <br /> DDENDUM/ADDTNL INFO RECVD ( DENIED REVISION DUE <br /> ERMIT ISSUED SPECIAL PERMIT ISSUED DTHER AGENCY DUE DATE <br /> RKPLAN APPROVED COMMENT LTR SENT ILLING FORM SUBMITTED <br /> FO GENC� SE EDD W <br /> Fee is Due: _Per Unit _Per Site Zch <br /> illing emittance Amount Remit Checked <br /> Program Element Fre ExpLanation Date Date emitted MOUNT DUE Amount <br /> GT Corrective Action Oversight <br /> State/Federal Authorized) 53.00/hr 5 hour minimum <br /> azardous Material Transmission <br /> ipeline Assessment Oversight 53.00/hr 5 hour minimum <br /> nvironmentaL Assessment Work Plan/ <br /> eport Review and Inspections 53.00/hr 3 hour minimum <br /> ther Government Oversight Work Plan/ <br /> Report Review and Inspections 53.00/hr 3 hour minimum <br /> eceived By ate Feceipt No. [ssuance Date ailed <br /> PAGE TWO OF TWO <br /> EH 23074 (2/91) 89-006(VI)2/91 BILFRM12B <br />