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. r POE. <br /> SAN JOAQUIN r'' -Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL N 'H DIVISI <br /> NON-C�rd1TE MITIGATION/ASSESSMENT SUBMITTAL LOG `� 015l <br /> ♦ 4 <br /> SITE ADDRESS 15 C LEAD AGENCY I/�n <br /> SITE CODE # {n PROG/ELEM T I 22-�-L BILLING CODE '75 SSIGNED TO Vy <br /> `TITLE OF SUBMITTAL: �� ` > �� TYPE CODE �7 <br /> DAZE RECEIVEDI G 7 DATE ON SUBMITTAL/ REQUEST --TOT <br /> 1 REQUEST DATE <br /> i <br /> PERMIT FEE PD CK WASH DATE R CK #/CASH DATE STAFF REVIEW DUE: <br /> � U / G �j \ OT SCHEDULED: <br /> S `)L,C v 2-S /��(C // 7 Z .25� � �zOT <br /> 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 REQSTD PR DUE <br /> RWOCB 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 ISSUED W / 8 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) 553.00/ <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 /> 'UL DESTRUCTION PERMIT APPLICATION $60.00 <br /> EACH <br /> APPLC <br /> EH 29 06 (BILFRMI2 revised 5/91) <br />