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SAti JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE RORKSHEET <br /> E fp y��T Rf�r-.-,6�f lz f A C I L I I Y CONTACT NANE �j�f/ r CYT2-1 <br /> ADDRESS /v/ �- SITE PHONE 11N •[A aoo[ _ <br /> 'sal%�Z/•5��� <br /> CITY ` , TUN "-� APPLICAHT <br /> I of Tanks <br /> ` �"� at Site ✓�� <br /> A APPLICANT/TILLING NAME CONTACT NAME <br /> 10 <br /> I MAILING ADDRESS <br /> A <br /> R CITY �T�� 1 P YPE ' PLICATION <br /> c�a�u[c, IM[ML111r1[M, nc. <br /> s <br /> A FACILITY FEE [ 1100.00 each SITE ADDRESS per YEAR V\J, M TOTAL <br /> 19862 �G1903 <br /> 1Goo0 1 — <br /> E TANK FEE • 150.00 each TANK — <br /> f 1 Tanks 1 150.00 1986 1387 1988 1983 <br /> A (muya(-by ice for —� <br /> I each ch year applicable) 1 <br /> L STATE SURCHARGE % 156.00 <br /> each TANK (see CA HEALTH k SAFETY CODE Sec 25281 for applicability) <br /> T I Tanks m 156.00 1986 1981 1308 1383 <br /> Y tenter HiNt and year) _ <br /> C PERMANENT CLOS E (Removal r Closure in-plate) <br /> l <br /> 0 CLOSURE FEE [ 190.00 each TANK <br /> S I Tanks 1 130.00 { Q <br /> U . <br /> P TEMPORARY CLOSURE (Only alloved one time for up to No years) <br /> E _ <br /> TEMPORAP,Y CLOSURE FEE s 180.00 each TANK _ �1 Tanks <br /> P PLAN CHECK (installation or Repair) — <br /> L <br /> A <br /> 11 PLAN CHECK FEE ■ 190.00 each SUBMISSION/RESUDMISSIOH — <br /> _ t <br /> REPAIR — --- — <br /> P TANK. REPAIR FEE • 1110.00 each TANK --------- <br /> ianksT i 1110.00 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION _ <br /> (vhen applicable) Wien applicable) (vhen applicable) <br /> FEE ■ 170.00/Iv FEE = 175.00/hr� FEE = 1]5.00/hr <br /> TOTAL DUE <br /> OFFICE USE aRtr <br /> 17��AfEVT� �9C,• Ct�Ih19E .IIp4t9 4m3�9i1{!F� <br /> SNEEPS 1 COMP I 40C CODE DIST CODE AMOUNT DUE AMOUNT RC V CIIEt CASH ^CVD BY DATE PECEIVED PEPMIi I <br /> Ii '7 h 1 / S---- iICIIIIII'1111' �I.fIMmnR�Y�mRmmGm�m ar{rmrmar�amni hnmnnmmie•+w,r••+,�.,+,�..._,.,.___,. <br /> C A r - ••+ OF n.._ ^nUrr •. a'n[•n._ +mall • CCVr,..- —,a. au. . --`WWWW ._. in - <br />