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• W .WO, <br /> SAN JOAQUIN LOCAL HEALTFI DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> FFACILITY/SITE NAME FACILITY CONTACT NAME <br /> Al <br /> G N_C r4: :5 4: -.Sis LC__-._— _Cc,fo' ti' I� ! <br /> L STREET ADDRESS 16 Ob vu r144H,3f=e rr j R °K SITE PHONE # NITN AREA COOc <br /> 4�_.__..... <br /> `T •3? — <br /> Y CITY S TA ijTF TIF CODE # of Tanks <br /> cf j 5 f ., at Site <br /> A APPLICANT/BILLlltii NAME APPLICANT CONTACT NAME <br /> P <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 "ITN AREA coos <br /> N CITY STATE IIP CODE TYPE of APPLICATION <br /> T Y' A.i. /n C �� �, CLOSURE, INSTALLATION, ETC. C <br /> .1_'.--- — --------.------------_..------ <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A _ _... __ _ _ .-._ . • ---- _ <br /> -� t986 _ 1997- �--1988_ 1183 <br /> E TANK FEE = 150.00 each TANK <br /> .............__................-..1-11....1.........._.......-1111-...._ 1.......1..............-.. .-- - -- - _. ......_._...... 1111- ..............._.............. --- 1-111-_.._.._-_...__._......_. <br /> F # Tanksx 150.00 1996 11 1988 1983 <br /> A (multiply_1_by fee for ----.-.—_.......__- <br /> C each year applicable) f <br /> I ____._...---1-1-11_._----.-.-.-- ------- -----.. ----11-11---------1-1-11-_ ---- <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x $56.00 1386 1987 1988 1983 <br /> Y (enter iii555t and year) -------..... ____---•------ ------1111. ---.._.._.._.---- ----- -------- <br /> --------_-------------------- ___........___..._____---•------ -----111-1...--- ___.� _-'----s--- ----- <br /> .................._._..__.__.----,.........__......____._.._._.._.._-___-._..---.-----1--11-1-_-111-1..---.-_------ - <br /> -— <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L __......_.._._.__.._.___........__-.._...._...___-.......____.------_......__._.____..__......_.__ ..-------_1-111-------1-1-11-...----------•-- -----. —__----- <br /> 0 CLOSURE FEE = 190.00 each TANK 1 an s--z- x 130.00 1 �•�) <br /> 1 .............. _..._..-1-111-_-...._..._ - —---------._-- -- -- -_ —_ -- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK # Tani--- <br /> anix 180.00 f <br /> ----•-- <br /> P PLAN CHECK (Installation or Repair) L �l <br /> - <br /> A ._...... ---FEB � � 1990.._....... ......-------------- <br /> L --- <br /> tl PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION f <br /> TSG ( EN)n ,:—i'iG_--- ----. . _ -- ---------- <br /> ------------ — 'IT7 ar-_...__J_LL 1 --- ----- — <br /> REPAIR <br /> F TAN) REPAIR FEE = 1110.00 each TANK 15 <br /> 1 Tanks x 1110 00 1 <br /> E- <br /> .. ... ....... . 771-111-.. ... .. .._ 11-11— . .. .. .............. <br /> -- - <br /> p <br /> A PIPING P.EPAIR/CLOSUP.E/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> -__- -. ----------------- - ---- --- - <br /> F. UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SANPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE 1°0 OiVhrl FEE 135 00lhrl FEE 135 OO/hrf 1 <br /> ------- <br /> I\c CA 1c\gD TOTAL DUE f f 3 (1 p <br /> OFFICE USE ONLY ka dor Cc e6\-. - yeA SSo2 \S -- -` - <br /> NG!�I1 11'FG M�9fiIRM11311i1 fi l!GGG9GIGG1G1NINi G�GGGGEGN!!ANMNNININN'ilGGfi!i!ilGll!I�NNNiG!IGfiG111iGIG1111!iINiGIliGG11•;i!IifIiNIGi.NGGllll1�?fiGN!iG':IENNIGN�IIfiN� 9GPN!!GGiNNII!I!91NNill!NG 1Gpj� <br /> �NtDPG'�M�!�G�IGGN@NNNII : . ,. IINgN���1�4G�1� _ <br /> SUEEPS A COMP 1 LDr CODE DIST CODE AMOUtIT DUE AMOUNT REVD CHECK 1/rh;N RFVD BY DATE RECEIVED PEenli k <br /> ----- - <br /> IV 5 e-O <br /> r1:,mgmi��ileirrN���MG;flr l!IGO GNGIIIINN!I!I!INII! ,'IIG;I!IGGGGfII'N:.GIiGiGGI�N�!fiGG!fGl!!Glhi'!NNGI!li'INNflfGNGIIGBGIIGINI IIG�GIIGIIIGGGIl1G�Nll!I G!IGNG'�NII91flIIG!!NIG.�III�II�IGIIIIIGGGUIINN9GIIGG9I GNINiiIP.IIBINIM11NGl!11NIy�i <br /> E1 7 3� .Ea fir 9 <br />