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SAN`JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE NORKSHEET _— _--_---_ <br /> FrFP.C[LITY/SITE NAMEFACILITYCONTACTCONTACT NAME <br /> Ifr SHELL 5�1' �tG sTATlo�l paN J . TAkAHA5.1-11 <br /> 1 - - — SITE PHONE f IrH "�EA CODE <br /> STREET ADDRESS 13 v �AZ-� 2�1/ Qj 43 �S <br /> Y CITYSTATE ZIP CODE f of Tanks <br /> �jr �0}J GA �l�'1�7f at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Pp �S€>zT I-1 L .45506. JEFF TA%�Iz <br /> L ---- --------- -- ------- - --- <br /> I MAILING ADDRESS APPLICANT PHONE f WITH AREA CODE <br /> /�1/•�_ _�2t <br /> A ---- ---- -— —---------- Giogy <br /> N CITY �1c�tf �r-� STAT[14.5 ZIP •CODE TYPE of APPLICATION [ <br /> T— GJ/G4 � � - cLomumE, rHErAunrIOH, ErC`IH`�?4L�-A <br /> FACILITY FEE _ $100,00 each SITE•ADDRESS per YEAR TOTAL. <br /> A _-- ----- -------- <br /> �— - --- -- - - - ------- <br /> T •- 986- ---198 -1988 - - � - <br /> -8�� <br /> 1 <br /> E TANK FEE _ $50,00 each TANK <br /> F f ranks x $50.00 1986 1987 1988 1989 <br /> A (multiply i_by fee for <br /> C each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH G SAFETY CODE Sec 25287 for applicability) <br /> T t Tankk-3 x 156,00 19861987 1988 1989 <br /> Y (enter amount and year) —• <br /> '- •-----------------�--- -� � <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) - - - - <br /> L - - ---- -— ---- — -- <br /> 0 CLOSURE FEE : 190,00 each TANK f Tanks--3- x $90.00 7O 00 <br /> S ------ --- ----- <br /> U ------ --- - —-- - <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E ---- — --- ----- -- --TEMPORARY CLOSURE CLOSURE FEE _ 380._00 each TANKflank x 180.QO f <br /> P PLAN CHECK (Installation or Repair) — -l� k'„ <br /> I11 PLAN CHECK FEE = 130,00 each SUON[,SSION/RESUBMISSION FNS/ 7,9,9: _- f �jDA00 <br /> REPAIR ---- ---p�ZrM/TSS —y� �- --- <br /> R TANK REPAIR FEE _ $110.00 each TANK # Tanks CzfS11J;0e S <br /> E - -----._.--.--__..... ----- -._ —___. - - -'- ---- -- ——----- <br /> F --_ - - --- ----------- --- <br /> A PIPING P,EPAIP./CLOSURE/REMOVAL (Fees are per hour, minimuu one hour to be paid. on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IISPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.001hIr FEE = 135.00/hr� FEE _ $35.00/hr <br /> ------------------•--------- -TOTAL DUE f C� <br /> OFFICE USE ONLY <br /> �.�7�4"�1 9V I� V2AI� R.9P,Q949PN9449n@ ,. 9�192111�Sa 9P " 6��m�l�ll."ll� V��llA!�LRU9111-MIRI MIRIN1010110 •. ��2GNaEM1 1T.. o'BIIMnms Rffi�. <br /> SNEEPS f COMP p LOC CODE DIST rrnE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH £CVD BY DATE RECEIVED PERMIT 1 <br /> U� F1f 3 O �•• o0 0 �' , a.G1j�4P� .I�N19f6i&V99�@I9LICPIIVPIPIIti <br /> 9� 9.. q� �4P �p !�!P4!II LIIfi41fl n%4118P?!1�eELRIII I [�PGI�9!�IIIP'Pil�[�.�19�m�NHf�@IIPgVY@IIC IM�fl �GG�GI@ �9'�II �'Ig . JIMI�IOI�VI47R <br /> r2'REV�EU '(`7'7 8 <br />