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SAN JOAQUIN OY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL 0H DIVISION �- �I <br /> NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG 1% # <br /> SITE ADDRESS LE A* <br /> i <br /> SITE CODE # 6Y /, PROG/ELEMENT BILLING CODE SIGNED TO <br /> TITLE OF SUBMITTAL: C.J /, TYPE CODE J .� <br /> DATE RECEIVED --�-4/ -, DATE -ON SUBMITTAL ✓Ji OT REOUE TOT REQUEST DATE <br /> PERMIT FEE PD CK #/CASH DATE REVIEW FEE PD CK #/CASH DATE STAFF REVIEW DUE: <br /> 0T SCHEDULED: <br /> $ f OT COMPLETED: <br /> ACTION DATE ACTION DATE ACTION DATE <br /> ACKNOWLG/COMMTMNT LTR REQSTD INCOMPLETE/ADDTNL INFO REQSTD SRP DUE <br /> ACKNOWLG/COMMTMNT LTR RECVD REVISION REOSTD PR DUE <br /> RWQCB COMMENTS REPORT REVIEW COMPLETE PAR DUE <br /> OTHER AGENCY APPROVAL FILE/NO ACTION FRP DUE <br /> ADDENDUM/ADDTNL INFO RECVD DENIED REVISION DUE <br /> PERMIT ISSUED7W / B SPECIAL PERMIT ISSUED OTHER AGENCY DUE DATE <br /> WORKPLAN 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) $53.00/ <br /> HOUR 5 HOURS $265.00 <br /> HAZARDCUS MATERIAL TRANSMISSION 553.00/ <br /> PIPELINE ASSESSMENT OVERSIGHT HCUR 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 AMOUWS RECEIVED DATE PERMIT ISSUANCE <br /> PERMIT ACTIVITY FEES FEE RECE1'7ED 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 />