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STATE OF CALIFORNIA-THE RESOUR&&S AGENCY <br /> DEPARTMENT OF FISH AND GAME � 10253940 <br /> ENVIRONMENTAL FILING FEE CASH WFEIPT <br /> DFG753.5a(M3) <br /> Lead Agency: Date: <br /> County/State Age of Filing- Documen(NO.: <br /> Project Title: A-In <br /> Project Applicant Name: Phone Number: <br /> Project Applicant Address: <br /> Project Applicant(check appropriate box): Local Public Agency School District Other Special District <br /> State Agency Private Entity El <br /> CHECK APPLICABLE FEES: <br /> Environmental Impact Report $850.00 $ <br /> Negative Declaration $1,250.00 $ <br /> Application Fee Water Diversion(State Water Resources Control Board Only) $850.00 $ <br /> Projects Subject to Certified Regulatory Programs $850.00 $ <br /> County Administrative Fee $25.00 $ <br /> .)-Ko�ject that is exempt from fees <br /> TOTAL RECEIVED $ <br /> Signature and title of person receiving payment: <br /> WHITE-PROJECT APPLICANT YELLOW-DFG/FASB PINK-LEAD AGENC( (1GOLDENROD-STATE AG&OF FILING <br />