Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME — FACILITY CONTACT NAME <br /> Te-v*/i s4 <br /> L STRE�ADDRESSE HONE t <br /> • � ' �yG . <br /> r - 1 "x TN ARSA cone <br /> Y CITY `T AT ZIP CODE It of Tanks <br /> at Site <br /> AA APPLICANT/BILLING VAME^— APPLICANT CONTACT NAME <br /> 1 MAILING ADDRESS APPLICANT PHONE If N'T" AREA coot <br /> •--._� _..�__�r_�.�_�,�2(ez_ <br /> N CITY �yATATE 21P CODE TYPE of APPLICATION <br /> T S MFX710-0.00 <br /> CA7 C / CLOSURE, INNTAUATION, ETC.H- Z�__ cLosl-t^FACILITY each SITE ADDRESS per YEAR TOTAL <br /> A ...__.—.—_ -- — -- - __ -- ...._..__..-- _ ............... -- --- — — <br /> T 1986 ^ --•• 1981_-- 1988 1589 t <br /> I <br /> V- — <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks x 150.00 1986 1987 1988 1983 <br /> A (multipfy I by fee for -- — ---- —. <br /> C each year applicable) $ <br /> I — <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTN L SAF for applicability) <br /> 1 — -- — <br /> T 1 Tanks x $56,00 1986 1981 1988 1989 <br /> Y (enter aioun-and year) <br /> PUB L C HEALTH SE VICES ��_ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) —— — — <br /> L �--- ---.----......----- <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks Z_ x $90.00 $ <br /> U -- <br /> P. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E ----- <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks x $80.00 $ <br /> P PLAN CHECK (installation or Repair) <br /> L — <br /> A <br /> M PLAN CHECK FEE $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR -----.____�—__—• — _ _-- <br /> P. TANK REPAIR FEE _ $110.00 each TANK - _ -- - - t Tanks —- x $110.00 <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 /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.007hr FEE = $35hr FEE _ $35.00/hr $ <br /> TOTAL DUE is I jd:z) O O_ <br /> OFFICE USE ONLY <br /> R!G!: G IIGIGh6G1�IpGGGII I!! I IGIG@II9'19G9IIGd111GGG911G!I IRIGGG9GmJGGCIICG1ll@GGC i°GGfI!!IiIIGi11Gi@":iPGRGGG!IGGGG!I91P.VGIGIIGI'7!GuGG!' 'GIIu�iVlllifG11i91GIGil!Iliill!IIGI1'rufliG1:iiGSG1111189CG!GiIIGiGGGIC9GIG911I 91�IP�GI�IGGGG?1Gtil�!Ci1CG `' <br /> ;WEEPS tCOME $ LOC CODE CODE AMOUNT DUE AMOUNT RCVD CfIECK /SASH RCVD BY DATE RECEIVED PERMIT t <br /> ) Ilil i r u rl ,i ri ,Rr <br /> � C C e c- l Z c 37 � V" � -2 �;i /✓� <br /> ���.Ot"GI!I!RRI�RRGN1iG!b.Rm:aG��PRG�iII:',Ii!IIRGVRRRRI'n�IJ!!'i9l!IRJ�IGG �iIIG�I!111111991iIIGi!C ��119GGGRGIIGi�.,.fiR IIIGGRRYIVRIIRGuRDGI�IRIIRGIGmMVIIiPGYGGG.uI!I�GNG�IGG!9�IAI�1"IGi'M�IG��I: <br /> l.rB'e <br />