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SAN TOAQUIN LOCAL HEALTH DI — S"RICT �ER6 OUND STORAGE TANK PROGRAM - FEE WORKSHE IA FACILITY/SITE NAME FACILITY CONTACT NAME ��— L STREET ADDRESS 1, — SITE PHONE I WITH AREA CODE T---- Y CITY STATE ZIP CODEI of Tanks _ �G}{7�t� — Cf} Cc at Site A APPL ICAN T/BILLING NAMME,/ APPLICANT CONTACT NAME L I MAILING ADDRESS APPL NT PHONE I NtTH AREA CODE C /yU --�Z/ . nli ak 1 er _ 3, Z/S 3 A CITY STAT ZIP CODE TYPE of APPLICATION EX iS -,.-- -('� IJ �S2.QT CLOSURE. INETALLATIDNr ETC. n/L�Lr FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL A — --- --- --—a(D) --/27 —C197 198A 1989 TV r-6 $ o=. E TANK FEE _ $50.00 each TANK F I Tanksx $50.00 1986 1981 1988 — 1989 A (multipi�by fee for C each year applicable) �� f — —/ 7 L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) I -- -- T I Tanks� x $56.00 Y enter amount and year) 198 7 _-198G 1989 ( — C PERMANENT CLOSURE (Removal or Closure-in-place) L —_--.. -- -- -- --- 0 CLOSURE FEE _ $90.00 each TANK — —_—r t Tanks x $90.00 f S — — — U --- --- — — -- -- -- P. TEMPORARY CLOSURE (Only allowed one time for up to two years) E-- — —TEMPORARY CLOSURE CLOSURE FEE = $80.00 each TANK I Tanks x (80.00 f P PLAN CHECK (Installation or Repair) -- N PLAN CHECK FEE =_$30.00 each SUBMISSION/RESUBMISSION — $ REPAIR — — — R TANK REPAIR FEE = $110.00 each TANK I Tanks x $110.00 f E-- .---- ----- ----- ---.._. 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 SAMPLING INSPECTION (when applicable) (when applicable) (when applicable) FEE = $30.00/hr:[_ FEE _ $35.00/hr FEE = $35.00/hr f — - ----�-- Dff10E USE ONLY TOTAL DUE 17ZLOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT I � 181 'I(DB �,�. — - ---