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Y SAN JCAOUI' TY - PUBLIC HEALTH SERVICES/ENVIRONMENTA LTH DIVISION 0 <br /> NSITE MITIGATION/ASSESSMENT SUBMITTAL LO 42L-, a _ <br /> SITE ADDRESS Q LEAD AGENCY <br /> SITE CODE # PROG/ELEMENT 2f �Q BILLING CODE 5 ASSIGNED TO <br /> TITLE OF SUBMITTAL: TYPE CODE Q� <br /> DATE RECEIVEDIIDATE ON SUBMITTAL DT/REQUEST OT REQUEST DATE <br /> PERMIT FEE PO C #/CASH DATE REVIEW E CK #/CASH DATE d STAFF REVIEW DUE: <br /> OT SCHEDULED: <br /> Si60) /Q 3 4 S�j v / OT COMPLETED: <br /> 3 Y7 <br /> ACTION DATE / ' ACTION DATE ACTION DATE <br /> ACKNOWLG/COMMTMNT LTR REGSTD INCOMPLETE/ADDTNL INFO REGSTD SRP DUE <br /> ACKNOWLG/COMMTMNT LTR RECVD REVISION REGSTD PR DUE <br /> RWGCB COMMENTS REPORT REVIEW COMPLETE PAR DUE <br /> OTHER AGENCY APPROVAL FILE/NO ACTION FRP DUE <br /> ADDENDUM/ADDTNL INFO RE CVD DENIED REVISION DUE <br /> PERMIT ISSUED FlW / B SPECIAL PERMIT ISSUED OTHER AGENCY DUE DATE <br /> WORKPLAN REVIEW COMPLETE COMMENT LTR SENT PROJECT CCMPLETE/FINAL BILL <br /> FOR AGENCY USE ONLY <br /> SITE MITIGATION PROGRAM FEE BASE MINIMUM HOURS MINIMUM AMCUNT RECEIVED DATE RECEIPT AMOUNT <br /> SCHEDULE FEE FOR SERVICE FEE RECEIVED BY # DUE <br /> LOT CORRECTIVE ACTION OVERSIGHT (CAP) $53.00/ <br /> HOUR 5 HOURS $265.00 <br /> HAZARDOUS MATERIAL TRANSMISSION 553.00/ <br /> PIPELINE ASSESSMENT OVERSIGHT HO R 5 HOURS $265.00 <br /> ENVIRONMENTAL ASSESSMENT WORKPLN/ $53.00/ I <br /> REVIEW AND INSPECTIONS HOUR 3 HOURS 5159.00 <br /> OTHER GOVERNMENT AGENCY OVERSIGHT 1553.00/ <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 /> (monitor!rg/extraction/vapor Wells, EACH <br /> soil borings, vapor surveys, etc.) APPLC <br /> WELL DESTRUCTION PERMIT APPLICATION $60.00 <br /> EACH <br /> APPLC <br /> EH 19 16 11ILFRMI2 revised 5/91) <br />