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SAN�JOAQL3IN LOCAL HEALTH Dr6TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> F FACILITY/SITE NAME ^— FACIW TY CONTACT NAME <br /> I <br /> Noir-- J) 1 �0P1S co <br /> L STREET DDRESS SITE PHONE 1 ` H nmu come <br /> 13� c � hn QR_ 1 Q <br /> Y CITY AT IP COD 1 of Tanks <br /> 9ac� at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT TIME <br /> I MAILING ODRESS APPLICANT PHONE 1 wITM *cca came <br /> N CITY ��j�� TE TYPE of APPLICATION <br /> T � ,` ttacwa, IInTAuereoee, ■rc. ( j1'x y4QL <br /> FACILITY FEE z $100.00 each SITE ADDRESS per YEAR — TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 Ym $ <br /> V <br /> E TANK FEE _ $50.00 each TANK V <br /> F I Tanks x $50.00 ^ 1986 1987 1988 198 2 Q <br /> A (multiply-1-by fee for <br /> C each year applicable) Rp f <br /> I ..�. <br /> L STATE SURCHARGE ° $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for <br /> I S <br /> T 1 Tanks w 456.001986 1981 1988 1983 <br /> Y (enter iiouit and year) F: <br /> 4 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L O� <br /> 0 CLOSURE FEE = 190.00 each TANK 1 TaAhs______ x $90.00 t _ <br /> 5 <br /> u — <br /> R TEMPORARY CLOSURE (Only alloyed one time for up to tvo years) <br /> E -- — — <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK rl Tanksx $80.00 4 <br /> P PLAN CHECK (Installation or Repair) <br /> L - ------ <br /> A <br /> —A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR — <br /> P. TANK REPAIR FEE = $110.00 each TANK 1 Tanks x $110.00 t <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I ----- --- — —� <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (vhen applicable) (when applicable) (when applicable) <br /> FEE = 430.00/hr FEE _ $35.00/hr FEE = f35.00lhr 4 ^ <br /> TOTAL DUE s`� <br /> OFFICE OSE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD cLtlEGK�/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> NamEL b tf�.0 - <br /> �"1 *� <br />