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r <br /> 1 <br /> SAN JLOUIN LOCAL HEALTH DISTAT la <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> /�R <br /> TE NAME FACILITY CONTACT NAME <br /> ESS SITE "ONE t NIT" AREA COOL rJ <br /> T <br /> Y CItY ST TE lip CODE 1 of Tanks <br /> -�S-=c2C Td -- 6Z at Site - <br /> A APPLICANT/BILLIM6 NAME APPLICANT CONTACT NAME <br /> P <br /> P �IOUC_Ca _ C�1LCd�_—>!. .i totit -f�a -� I L � LC,4FfCf <br /> 1 M1 IN_G ADD�SS APP CANT PONE 1 WITH AREA COOL <br /> N CITY f --— T T LIP CODE APPLICATION <br /> �. _C>Glt=�-d� � CLOLOLL INSTALLATION. ■TO.0&C <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR I TOTAL lL <br /> A ------ -- --- — <br /> 198 — 1987 1988 1 1989 f <br /> V }L- <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks —s 150.00 -- 1986 1981 1988 1989 <br /> A (Lultipty_1_t fee for --- — <br /> C each year applicable) f <br /> 1 -- — <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> ----- <br /> i 1 Tanks 1 156.00 1986 1987 1988 1989 <br /> Y (enter iioiit and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> D CLOSURE FEE = $90.00 each TANK — t Tanks_ : $90.00 5 �Leo <br /> S -- — <br /> U --- — <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E — -- — <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK —�1 Tanks _x $80.00 5 <br /> P PLAN CHECK (installation or Repair) <br /> A <br /> 11 PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION 5 <br /> REPAIR — <br /> R TANK REPAIR FEE = 1110.00 each TANK 1 Tanks x SI10.00 5 <br /> E _ --- --- - - - _ <br /> P ----- ------ -- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr FEE_135.00/hr�— FEE = $35.00/hr --- $ — <br /> TOTAL DUE Is d ` <br /> OFFICE USE ONLY <br /> SNEEPS_I COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CNECK /CASH RCVD BY GATE RECEIVED PERMIT 1 <br /> --- --. —_ _._...... ............_.._ <br />