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i <br /> SAN JOAQUIN TY SERVICES/ <br /> ENVIRONMENTAL& - PUBLIC HEALTH SERVICEENVIRONMENTAL 1 N DIVISI "1 <br /> NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG # - 2 <br /> SITE ADDRESS LEAD AGENCY <br /> SITE CODE # PROG/ELEMENT 12_,7�(� BILLING CODE 5 ASSIGNED 0 �A • <br /> TITLE OF SUBMITTAL: TYPE CODE <br /> DATE RECEIVED DATE BMITTAL OT REQUEST OT REQUEST DATE <br /> PERMIT FEE PD CK #/CASH DATE REV1E FEE PD CK #/CASH DATE STAFF REVIEW DUE: <br /> OT SCHEDULED: <br /> $ r 9 OT COMPLETED: <br /> ACTION DATE ACTION DATE ACTION DATE <br /> ACKNOWLG/COMMTMNT LTR REQSTD INCOMPLETE/ADOTNL INFO REQSTD SRP DUE <br /> ACKNOWLG/COMMTMNT LTR RECVD REVISION REQSTD PR DUE <br /> I <br /> RWQCB COMMENTS REPORT REVIEW COMPLETE PAR DUE <br /> OTHER AGENCY APPROVAL FILE/NO ACTION FRP DUE j <br /> ADDENDUM/ADDTNL INFO RECVD DENIED REVISION DUE <br /> PERMIT ISSUED. W / B 31 SPECIAL PERMIT ISSUED OTHER AGENCY DUE DATE <br /> 1 � <br /> WORKPLAN REVIN COMPLETE ` j OMMENT LTR SENT PROJECT COMPLETE/FINAL BILL k <br /> FOR AGENCY USE ONLY <br /> SITE MITIGATION PROGRAM FEE BASE MINIMUM HOURS M3NIMU4 AMOUNT RECEIVED DATE RECEIPT AMOUNT ` <br /> SCHEDULE FEE FOR SERVICE FEE RECEIVED BY # DUE <br /> i <br /> UG1 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 # 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 />