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SAN JOAQUIN, �NTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL _CTH DVISI <br /> NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG #�• <br /> SITE ADDRESS LEAD AGENCY /fin <br /> SITE CODE # / pROG/ELEM T 122. �_ BILLING CODE 1 ASSIGNED TO <br /> TITLE OF SUBMITTAL: / /,�/ TYPE CODE <br /> DATE RECEIVED I DATE ON SUBMITTAL// REQUEST OT REQUEST DATE <br /> PERMIT FEE PD CK #/CASH DATE REVIE FEE CK #/CASH DATE STAFF REVIEW DUE: <br /> OT SCHEDULED: <br /> $ ZSG�U� / 2 S/ 25" ZU �y OT COMPLETED: <br /> ACTION DATE ACTION DATE ACTION DATE <br /> ACKNOWLG/COMMTMNT LTR REOSTD INCOMPLETE/ADDTNL INFO REOSTD 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 ISSUED W / 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 /> 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 9� <br /> (monitoring/extraction/vapor wells, EACH <br /> soft borings, vapor surveys, etc.) APPLC ` ! 0/67 <br /> WELL DESTRUCTION PERMIT APPLICATION $60.00 <br /> EACH <br /> APPLC <br /> EH 29 06 (BILFRMI2 revised 5/91) <br />