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aaN JUAQUiN LOCAL HEALTH DISTRICT UNDERGROUND STORAGE TANK PROGRAM - FEE NOR T F FACILITY/SITE NAME __- ,F T FACILITY CONTACT NAME L STREET ADDRESS I SITE PHONE 1 WITH AREA cost T ..._.._—_._--__. .f11 tY:LC►u¢n_Sf_. — oNF Y CITY STATE ZIP CODE 1 01 Tanks ak Site A APPLICANT/BILLING NAME P APPLICANT CONTACT NAME F /r I MA[LjNG ADOP,ESS r� APPLICANT PH NE t WITH AREA coot N ...---------- ..__. __ .2 0 6�_ TN CITY STAT ZIP CODE TYPE of APPLICATION -� — .._... cIOtlMlt. INtT��LATION. tTc. (FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR A __.._._.__._....___._._..._.._..._._...._ TOTAL C --- - — T 1986 1987 1988 1989 ----- --------- E TANK FEE = 550.00 each TANK F t Tanks x 550.00 --- ------ .............. _ A (multipearF-by fee ler 1986 1987 �9gg 1989 _ C each year applicable) L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 4 SAFETY �- Y CODE Sec 25287 for applicability) T t Tanks x 156.00 1966 1981 1988 Y (enter iiHit and year) --- _ 1989 C PERMANENT CLOSURE (Removal or Closure in-place) - - L - ----'— - --- 0 CLOSURE FEE = 190.00 each TANK S -t Tanks__ z 190.00 U R TEMPORARY CLOSURE (Only allowed one time for up to two years) E - TEMPORARY CLOSURE FEE = 180.00 each TANK -' - - t Tanks_ - x 180.00 1 -- P PLAN CHECK (installation or Repair) L - --- --- - — - p -- - - -- —. - _- -IN PLAN CHECK FEE = 100.00 each SUBMISSION/RESUBMISSION — f REPAIR P, TANK, REPAIR FEE = 1110.00 each TANK E •...------- -- - —_-- 1 Tanks...... x 1110.00 1 P - _.._..._-.--._.. A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) - - R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION (when applicable) _ _ (when applicable) SAMPLING INSPECTION (when applicable) FEE = 130.00/hrI TOTAL DUE 1 'p _- OFFICE USE ONLY ra__ SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCV �� VG�IIil" -�--- 0 1/CASH RCVD BY DATE RECEIVED PERMIT 1 - ..._. _ ..._. 1 _....