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SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> e FACILITY/SITE NAME _ — FACILITY CONTACT NAME <br /> `�I�kt�n f, Lnc;�uS�f TEs Frei �Je( �s <br /> L STREET MORESs SITE P ONE 1 Tell MIM CON <br /> al�ll �ntL�4S�Y1 �� ��� jq - 9701 <br /> Y CITY I $jAT 11P CODE 1 of Tanks <br /> �Il) �L�ClY1 Lln �SduS at Site <br /> A APPLICANT/IILLINS NAME APPLICANT CONTACT MME <br /> P <br /> P F`� uS,Un Lu�c����rles Ke_� �_amcc rIFT <br /> I MAlli1N ADDRESS - - APy LICANT PHONE 1 ware mA coos <br /> lull � . P�rSI�( �C _ _ (a0�1) lba - 9,i II <br /> 1 CITY CC l j $JAT iIP CODE PE--ol APPLICATION <br /> c� I (J- i-7S1�1 (fit cl- <J-0 L <br /> fkclLIIY FEE a $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1906 1927 1908 1589 <br /> v IOU { aCa)- <br /> E TANK FEE 1 150.00 each TANK _ _— _ I OL) <br /> f 1 Teske _ e 150.00 !1986 198] 1988 198'1 <br /> A Inwltioly 1-by Ire for <br /> C sack year applicable) ,p ' ► I uG — <br /> L STATE SORCHARGE m 156.00 each TANK (sea CA HEALTH 6 SAFETY CODE Sec 25201 Ior�pplPii�iS <br /> 1 <br /> I 1sante__• 1 156.00 1986 1981 - 1988 1989 <br /> Y later Await And year) <br /> C PERIIW1 CL850RE (Reveal or Closure-in-pla(e) —~ ---- <br /> L <br /> 0 CLOSURE FEE m 190.00 each TANK 1 Tanks I 1 {90.00 1 q� <br /> 5 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) — <br /> TEMORARY CLOSURE FEE ■ 180.00 each TANK Ti-Tanks 1 180.00 1 <br /> 11A11 CHECK (installation or Repair) <br /> A - -- - - -- <br /> N PLAN CHECK FEE m 170.00 each SU/MISSION/RESUBMISSION 1 <br /> REPAIR -- --- I <br /> I TANG REPAIR FEE m 1110.00 each TANK 1 Tanks _ 1 t110.00 { ` <br /> A PIPIMS REPAIR/CLOSURE/REMOVAL (fees are per hour, minimum one hour to be paid on plan submittal) <br /> R WIAUIWIIIEI RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> Iwhen appli ibis) (when applicable) (when applicable) <br /> FEE m {00.00/kr FEE m 175.00/hrL FEE + f75.007hrl._.__— { <br /> TOTAL DUE 1 'meq LD � E <br /> MIIU ISE DRU' <br /> SWEEPS 1 COM 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO HEt 1/CASH RCVD DY DATE RECEIVED PERMIT 1 <br /> n <br /> ),'(kd/ i 3,a3 ' --�0o0 3 /C�- - -- <br /> S� � `I �Cc <br />