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SAN JOAQUf1TY - PUBLIC HEALTH SERVICES/ENVfRONMENTATH DIYI$ION <br /> NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG <br /> SITE ADDRESS Lz /1. <br /> LEAD AGENCY <br /> SITE CODE # PROG/ELIMENT 2g._. / BILLING CODELao /I <br /> < <br /> /ASSIGNED TO r <br /> TITLE OF SUBMITTAL: TYPE CODEW , <br /> DATE RECEIVED DATE OH SUBMITTAL zz�,411OT REQUEST OT REQUEST DATE <br /> PERMIT FEE PD CK #/CASH DATE REVIEW FEE PD CK #/CASH DATE STAFF REVIEW DUE: <br /> OT SCHEDULED: _/�/_ <br /> II2-4 3 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 REQSTD PR DUE <br /> RWQCB COMMENTS REPORT REVIEW COMPLETE PAR DUE <br /> OTHER AGENCY APPROVAL FILE/NO ACTION FRP .DUE <br /> [ADDEENDUM/AADOTNL INFO RECVD DENIED REVISION DUE <br /> 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 /> I <br /> UGI 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 853.00/ <br /> WORKPLAN/REVIEW AND INSPECTIONS HOUR 3 HOURS $159.00 <br /> i <br /> BASE AMOUNT RECEIVED DATE PERMIT ISSUANCE <br /> y k. <br /> PERMIT ACTIVITY FEES FEE RECEIVED BY # DATE L <br /> WELL/BORING-PERMIT APPLICATION $89,00 <br /> (monitoring/extraction/vepor welts, EACH <br /> soil borings, vapor surveys, etc.) APPLC; <br /> WELL DESTRUCTION PERMIT APPLICATION $60.00 } <br /> EACH <br /> i <br /> APPLC <br /> EH '29 06 CBILFRM12 revised 5/91) <br />