Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME -- <br /> A FACILITY CONTACT NAME <br /> C C;r ! _ <br /> I ✓ cH <br /> L STREET ADDRESS <br /> T —/ SITE PHONE 1 WITH ARCA CODE <br /> Y CITY STATE ZIP CODE 1 of Tanks <br /> Srocrr� v Zos at Site <br /> A APPLICANT/BILLING WANE <br /> P APPLICANT CONTACT NAME <br /> IUzi rdC�— - <br /> IMAILING ADDRESS APPLICANT PHONE 1 <br /> C WITH AREA coot <br /> A'-- % -Y/r) r'i!i J a77 i Y <br /> N CITY s� 3 :Zoy� <br /> T rnA! STATE 1IP CODE TYPE of APPLICATION r <br /> C A <br /> r-4 <br /> 0_T— CLoeuRC. INSTALLATION, ETC. <br /> FACILITY FEi = $100.00 each SITE ADDRESS per YEAR /1 <br /> TOTAL <br /> C 1986 1987 1986 1589 <br /> T <br /> I -- _ _ <br /> V $ <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks x $50.00 — 1986 1967 1988 --' <br /> A (each year by lee for 1989 <br /> C eul <br /> ach year applicable) — <br /> I $ <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> I — _— <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter ziount and year) -- � -- - <br /> C PERMANENT CLOSURE (Removal or Closure-in-place)— — <br /> L -------------- <br /> S0 CLOSURE FEE _ $90.00 each TANK 1 tanks ! x t90 00 $ <br /> --T---- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E --.— _ <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK, <br /> -- 1 Tan <br /> ksx $80.00 f <br /> P PLAN CHECK (Installation or Repair) .—- — — <br /> A -- -- __ <br /> II PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> — f <br /> REPAIR ---- — — -- — <br /> F, TANK, REPAIR FEE _ $110.00 each TANK --_-- — 1 Tanks_ _ x $110.00 $ <br /> E- <br /> P <br /> — --- <br /> P ---.-._._— __ ---==------- - <br /> A PIPING REPAID,/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I ------ _ <br /> R UNAUIHORIIED RELEASE=EVALUATIONNSTRUCTION INSPECTION SAMPIIHG IIISPECTION <br /> (when applicable) hen applicable) (when applicable)FEE = $30'00/hrLE _ $35.00/hr _ —� FEE _ $35.00/hr $ <br /> OFFICE USE ONLY TOTAL DUE $ <br /> C9 IG�9RC�CC1i� C�Y�C'C68�iCCCM .@�C.�000CVCC! OG'V"'�Cfi�WliGCfCCCfCI01Cl�!VV�II; C <br /> CIC'J�"JGiGIiJ C.�II�CCN�'CCiI000C�9NIC Omd�llI�C19C!!CC��I�CC� <br /> h SWEEPS 1 COMP 1 LOC CODE GIST CODE AMOUNT DUE AMOUNT RCVD H C t/rASH I RCVD DY GATE P C PERMIT t <br />