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140 ROD � � <br /> SAN JOAQUIN NTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL TH DIViSir%9g1 <br /> NON-LOP SITE MITIGATION/ASSESSMENT SUBMITTAL LOG , # _ <br /> .t <br /> 3 SITE ADDRESS <br /> LEAD AGENCY <br /> SITE CODE # 1-7�A PROG/ELEMENT 2? BILLING 056 S G ASSIGNED TO � <br /> TITLE OF SUBMITTAL: TYPE CODE <br /> DATE RECEIVEDD ATE ON&BMITTAL Or r / OT REQUEST JOT REQUEST DATE <br /> PERMIT FEE PD CK #/CASH DATE REVIEW FEE PD CK #/CASH 1� DATE STAFF REVIEW DUE: /— <br /> OT SCHEDULED: <br /> $ ��Gj ,�1 /_ / g i _ OT COMPLETED: <br /> t <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 /> :i <br /> OTHER AGENCY APPROVAL FILE/NO ACTION ii FRP DUE <br /> 4 ADDENDUM/ADDTNL INFO RECVD DENIED �1 REVISION DUE <br /> PERMIT ISSUED W / B SPECIAL PERMIT ISSUED t� OTHER AGENCY DUE DATE <br /> i <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/ f <br /> } HOUR 5 HOURS $265.00 <br /> i <br /> HAZARDOUS MATERIAL TRANSMISSION $53.00/ t <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 /> �f <br /> OTHER GOVERNMENT AGENCY OVERSIGHT $53.00/ <br /> WORKPLAN/REVIEW AND INSPECTIONS HOUR 3 HOURS $159.00 <br /> BASEAMOUNT RECEIVED DATE PERMIT ISSUANCE <br /> PERMIT ACTIVITY FEES FEE RECEIVED BY # DATE <br /> WELL/BORING PERMIT APPLICATION $89.00 <br /> (monitoring/extractiorVvapor wells, EACH <br /> Soil borings, vapor surveys, etc.) APPLC <br /> i <br /> WELL DESTRUCTION PERMIT APPLICATION $60.00 <br /> EACH <br /> APPLC <br /> EH 29 0(p (BILFRM126 revised 5/91) <br />