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Stata of Califomlo - Department of Fish and Wildlife <br />2021 ENVIRONMENTAL FILING FEE CASH RECEIPT <br />DPW 763.6a (REV. 01101/21) Praviously DFG 763,6o <br />.t. Prini„ = 1 Save - <br />30 —. 0910212021 — 0707 <br />LEADAGENCY EMAIL <br />CITY OF SANTA ANA 09/02/2021 <br />COUNTY)STATE AGENCY OF PILING DOCUMENT NUMBER <br />Orange 202185000732 <br />CAMPE;SINO, MEMORIAL, MADISON PARK RESTROOMS <br />PROJECTAPPLICANT NAME PROJECT APPLICANT EMAIL PHONE NUMBER <br />CITY OF SANTA ANA, PUBLIC WORKS AGENCY (714)647-5690 <br />PROJECTAPPLICANTADDRUSS CITY ISTATE IZIP CODE <br />20 CIVIC CENTER PLAZA M-36 SANTA ANA ICA 192702 <br />PROJECT APPLICANT f0back appropriate box) <br />[I✓ Local Public Agency © School District Other Special District State Agency Private Entity <br />CHUCK APPLICABLE FEES: <br />❑ Envirenmenlal Impact Report (FIR) <br />❑ MiggaladlNepaBva Declam8an (MND)(ND) <br />❑ Certified Regulatory Program(CRP)document - payment due directly to CDFW <br />0 Exempt from fee <br />E9 Notice of Examption (attaoh) <br />❑ CDPW No Effect Determination (atach) <br />❑ Fee previously paid (attach previously Issued cash receipt copy) <br />$3,446.25 $ 0.00 <br />$2,480,26 $ 0.00 <br />$1,171.26 $ 0.00 <br />❑ Water Right Application or Petition Fee (Slate Water Resources Control Board only) $850.00 $ 0.00 <br />❑ county documentary handling fee $ <br />❑ Other $ _ <br />PAYMENTMETHOD <br />❑ Cash ❑ Credit ❑ Check ❑ Other TOTAL RECEIVED It 0.00 <br />SIGNATURE AGENCY OF FILING PRINTED NAME AND TITLE <br />X / DEPUTY CLERK, CLAUDIA FRANCO <br />ORIGINAL- PROMOT APPLICANT COPY-ODW/Aae COPY -LEAD AGENCY COPY, COUNTY CLERK OM 751.60(Ray. 010120211 <br />