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UIN <br /> TY - PUBLIC HEALTH <br /> SAN JOAQNON•LOPSITE MITIGATION/ASSESSMENTSTASUBMITTALL LOG <br /> L 10TH DMS`ON1" <br /> SITE ADDRESS ?a LEAD AGENCY <br /> SITE CODE # PROG/ELEMENT 2 /n t'J BILLING CODE '��j ASSIGNED TO <br /> TITLE OF SUBMITTAL: —' <br /> 1 y TYPE CODE Q <br /> DATE RECEIVED '^y �/ DATE ON SUBMITTALg—//4 <br /> l_ 1/. OT REQUEST OT REQUEST DATE <br /> T / 'f <br /> PERMIT FEE PD CK #/CASH DATE REVIEW FEE PD CK #/CASH DATE STAFF REVIEW DUE: <br /> _ // OT SCHEDULED: <br /> $` G'v 2.(liG��� �5 �� 5 �S `�,UU 24260`I OT COMPLETED: <br /> ACTION DATE ACTION DATE ACTION DATE <br /> ACKNOWLG/COMMTMNT LTR REQSTD INCOMPLETE/ADDTNL INFO REQSTO SRP DUE <br /> ACKNOWLG/COMMTMNT LTR RECVD REVISION REQSTD PR DUE <br /> RWQCB COMMENTS REPORT REVIEW COMPLETE PAR DUE <br /> OTHER AGENCY APPROVAL FILE/NO ACTION ( P DUE <br /> ADDENDUM/ADDTNL INFO RECVD g. DENIED REVISION DUE <br /> PERMIT ISSUED W / B SPECIAL PERMIT ISSUED OTHER AGENCY DUE DATE <br /> WORKPLAN REVIEW COMPLETE COMMENT LTR SENT PROJECT CCMPLETE/FINAL BILL <br /> FOR 4GENCY USE ONLY <br /> SITE MITIGATION PROGRAM FEE BASE MINIMUM HCURS MINIMLM 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 /> F <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 5159.00 <br /> L— <br /> BASE AMOUNT RECEIVED DATE PERMIT ISSUANCE <br /> PERMIT ACTIVITY FEES FEE RECEIVED BY # DATE <br /> WELL/BORING PERMIT APPLICATION S89.00 <br /> (monitoring/extractiOn/vapor walls, EACH <br /> soil borings, vapor surveys, etc.) APPLC <br /> WELL DESTRUCTION PERMIT APPLICATION $60.00 <br /> EACH <br /> APPLC <br /> EH 29 C{, (BILFRMI2 revised 5/91) <br />