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SAN JOAQUIN QTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL QKH D <br /> NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG I # <br /> LLAD"A NICY <br /> SITE ADDRESS <br /> SITE CODE # 4 PROG/ELEMENT 22.� BILLING CODE ASSIGNED T04 <br /> TITLE OF SUBMITTAL: 7or 1-7 TYPE CODE <br /> �I <br /> DATE RECEIVED / DATE ON SUBMITTAL 9 OT REQUEST OT REQUEST.DATE <br /> I <br /> PERMIT FEE PD CK #//CASH DATE REVIEW FEE PD CK #/CASH DATE STAFF REVIEW DUE: <br /> J /�j� �} L( q1 OT SCHEDULED: _/ _/_ <br /> $ d <br /> l '"u ` L / 7 S .v u �j OT COMPLETED: <br /> ACTION DATE ACTION DATE ACTIJ1 DATE <br /> i <br /> ACKNOWLG/COMMTMNT LTR REQSTD INCOMPLETE/ADDTNL INFO REQSTD SRP DUE <br /> 1 <br />}}- ACKNOWLG/COMMTMNT LTR RECVD REVISION REQSTD PR DUE <br /> RWQCB COMMENTS REPORT REVIEW COMPLETE PAR DUE } <br /> a <br /># OTHER AGENCY APPROVAL FILE/NO ACTION FRP DUE <br /> 1 <br /> ADDENDUM/ADDTNL INFO RECVD DENIED REVISION DUE <br /> 1 <br /> PERMIT ISSUED W / B SPECIAL PERMIT ISSUED OTHER AGENCY DUE DATE <br /> t` WORKPLAN REVIEW COMPLETE COMMENT LTR SENT PROJECT COMPLETE/FINAL BILL <br /> FOR AGENCY USE ONLY <br /> t I <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 /> i HOUR 5 HOURS $265.00 <br /> s <br /> HAZARDOUS MATERIAL TRANSMISSION $53.00/ <br /> PIPELINE ASSESSMENT OVERSIGHT HOUR 5 HOURS $265.00 <br /> ENVIRONMENTAL ASSESSMENT WORKPLN/ $53.00/ <br /> I 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 /> i <br /> F <br /> 3 'f <br /> BASE AMOUNT RECEIVED DATE PERMIT ISSUANCE <br /> PERMIT ACTIVITY FEES FEE RECEIVED BY i # DATE <br /> I <br /> �- WELL/BORING PERMIT APPLICATION $89.00 II <br /> (monitoring/extraction/vapor wells, EACH I <br /> soil borings, vapor surveys, etc.) APPLC <br /> WELL DESTRUCTION PERMIT APPLICATION $50.00 <br /> EACH . <br /> 1 APPLC <br /> EH 29 (RILFRMI20 revised 5/91) <br />