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SAN JOAQUIN LOCAL HEALTH DVeTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME yr-£L �S <br /> L STREET ADDRESS SITE PNONE 1 WITH ARCA C009 <br /> ZZ <br /> Y CITYST T 7 COOS It of Tanks <br /> _ig�' L00/f/ at Site D/y <br /> AA APPLICANT/BILLING NAME APPLICANT <br /> CONTACT NAME eQLcL &QF S <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH ARCA CODE <br /> C PQ Qw <br /> A- <br /> TN <br /> CI1YQ� N STAT CODE PPLICATION <br /> CLOSURE NE TALLAiION._-C TC.-_- <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR W TOTAL <br /> T 1986 1987 1988 - 1989 <br /> I <br /> V f AM <br /> ati <br /> E TANK FEE =050.00 each TANK — <br /> F 1 Tanks z 150.00 1986 1987 988 1989 <br /> A (multipi [-by fee for 17 <br /> C each year applicable) �d f <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 4 SAF DE Sec oq a ca ility) <br /> I — <br /> T 1 Tanks 1 $56.00 E1986 9 98 <br /> Y (enter iiiiit and year) -- - - <br /> 0 <br /> CPERMANENT CLOSURE (Removal or Closure la <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks1 $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 1 $80.00 f <br /> P PLAN CHECK (Installation or Repair) --- — <br /> A — <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f —� <br /> REPAIR ___.—^--- --- -�----- <br /> ------ — <br /> R TANK REPAIR FEE^$110.00 each TANK -�— -- _ 1 Tanks 1 $110.00 -- <br /> E - <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 _ 130.00/hr� — - FEE _ $35.00/hrfFEE` $35_00/hr <br /> TOTAL DUE f �G <br /> 1 <br /> OFFICE USE ONLY <br /> SWEEPS n�lfl�.�"�UI�G9V I�u'NI!�ll'�I !Rll'p�99�J .UA� �V91�J�'!I��GI�VIR�9V��1"GOf�9Jl�!�IR�Ia111NIV099s11�19114@qVl�('i�Ilu�i��Ifil�iG�l�IG�I!:G,'1�11iVlQl�'!IIuY!!IIIUu"1'S��if�iliilf 7�9�1112�'V!�'1VUiIViIQIWIBN�J!NVVGGV�IV!�IIIVI!�V!GIVi�'dli�q!�� <br /> 1 ��a159. LOC CODE GIST CODE AMOUNT DUE AMOUNT�V0 HECK 2 VgSH_ ��DY D��REC3E�EO - PEP,MIT t <br /> COMP I ti <br /> �Emh ���� 9i���iV � lll�l��9' !!W�I!!19�L!IbVV�il� i 'I��1CVI!:II„���II���IIIN•.I!lllmd��,ai Ilnin�Inl�HlillQ�!il IlJlil!IIJIIIAVGI��III�III!RVII(IIVIIIIII!O�IIfdVI�I�VIII!9il �I!II�IINIIIII@��IIII��IIIIVII491��PdIIIIWNGG.111' I@49!IIVII1lli��l <br />