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SAk, JOAQUIN LOCAL HEALTH L „STRICT 1� . <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME — <br /> I <br /> L STREET ADDRESS SITE PHONE I Y1TN AREA emom <br /> I <br /> Y CITY STAT IIA CODE 1 of Tanks <br /> _. -- aLx Oso c(� at Site <br /> P APPI1CANi/BILLINB NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> 1 MAILING ADDRESS <br /> C V APPLICANT PHONE 1 M1TM AREA CODE <br /> A —_._. <br /> i CITY STAT ZIP'CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, ETC. <br /> FACILITY FEE = fI00.00 each SITE ADDRESS per YEAR Y-- <br /> _-._ _ _ <br /> —_ _ _ TOTAL <br /> C 1986 _ —1987 1988 _- 1989_ — - -- <br /> T <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanksj _ z 150.00 1986 1987 1988 — 1983 — <br /> A (multiply I by fee for <br /> C each year applicable) 5 O ":S C-> 5c' <br /> f <br /> 1 _— <br /> L STATE SURCHARGE _ (56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25281 for applicability) <br /> T 1 Tanks11 x $56.00 1986 1987 1988 1389 <br /> Y (enter aidunt and year) — �E- 7-- � <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — — --- <br /> 0 CLOSURE FEE _ (90.00 each TANK 1 Tanksx (90.00 1 <br /> 5 — <br /> U .. <br /> P. TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> E _ _ <br /> f. <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK —^ I Tanks-- x 0.00_T <br /> P PLAN CHECK (Installation or Repair) — —— <br /> L --_— — <br /> A - <br /> 11 PLAN CHECK FEE = 130,00 each SUBMISSION/RESUOMISSIOn $ <br /> REPAIR - -- --- <br /> P. TANK REPAIR FEE = 1110.00 each TANK - <br /> E - _. --. --.._...___— _1 Tanks-` x f I10�00--_ f <br /> A PIPING REPAIR/r,LOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) _ (when <br /> applicable) (when <br /> (applicable) <br /> FEE (35.0�/hr FEE30TL <br /> $ — _ <br /> OFFICE USE ONLY TOTAL DUE $ <br /> II�IIC'!@V”MOmGCIAIII�IPI���I�1�1!IIIf�6fl'Iu��C�@�cBgpmmlBC!iii191�"CCPa:",Ii�G99illlmla�ii�":Vl�!1I�n!CIG1f!!X91!!IGIfCi91'7!piliCm9�WCV�"mG"111i�I�I:TiI!liliIlV!J.fuCGG' fII�IV1�29RN7r1GilVG1G!�!1911PIp9Gf��i!��INE!!I�JI�IPI1�II <br /> � SWEEPS I COMP I LOC CODE DIST COE AMOUtIT DUE AMOUNT RCVD CHECK I/CASH I RCVD DY DATE RECEIVED PERMIT <br /> FC NS Slo (}� l Oct <br /> ��'119'TNtl e... 'l 'G9M , 91Nd�'�GC,p9911CP" !11 GBSIII�pfilp�llpl7�IImll�l�l'9�Ipf��n��!IlQii C�G9CU6VVCMIII���C@I. I!f1V'�19�1R9i1'�I�!B�OIICI��N�UII����VV99CIiIII�I�IGVii11P.RdII�I11�1TIVIICiIVi <br />