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SAN`9OAQUIN LOCAL HEALTH DimmORICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME — ---- FACILITY CONTACT NAME <br /> Lt wr*N ""�" eoo� <br /> STREET ADDRESS SITE PHONE <br /> ? ?� 2- <br /> Y CITY frr, S T IIP CODE t of Tanks <br /> �, at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L — — <br /> P MAILING ADDRESAPPLICANT HONEe <br /> & o' ' , ) 9ll- -4 7e2 <br /> N CITY 2E APPLICATION <br /> weu" tnr <br /> , ere. <br /> FACILITY FEE $100.00$100.00 each SITE ADDRESS per YEAR TOTAL <br /> C <br /> 1986 — 1987 1988 —1989 $ — <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks __—z $50.00 1986 1987 1988T— <br /> _ 1989 <br /> A (multiply f_by fee for <br /> C each year applicable) f <br /> I ---- <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I — <br /> T t Tanks z 156.00 1986 1987 1988 1989 <br /> Y (enter mount and year) — - <br /> C PERMANENT CLOSURERwoval ar Closure-in-place) <br /> 0 CLOSURE FEE _ $90.00 each TANK t Tanks__t._- z $90.00 fO a9 <br /> S <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E - <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks z $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L —_--- <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR -------.--___-- <br /> P. TANK REPAIR FEE _ $110.00 each TANKt Tanksz 4110.00 f <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 _ $30.00/hr� -- _— FEE _ $35.00/hr --- — FEE _ $35_004H $ <br /> TOTAL DUE f `fC_ G-g <br /> OFFICE USE ONLY <br /> d N'NPINILIf9NIRNINNN N�II!1�N1 NR� NmTmlI�IIKu RIMNNTRIN_I� 1n111Vry:1NI[IY <br /> SWEEPS 1 COMP t LOC CODE DIST CODE AMOUNT CHECK ASH BYRECEIVED —NN-N�M <br /> —. <br /> __..... <br /> Nrr �rI9N�NZ1 .. �REV5 � 8NI �hPPgNIIN1191NINaNIINIICPNNi18NI!IiFiIII IIIIiNNNmNINN!NN!V!'!INdl�l11!N!P�I�fNNlll�!NiIINII!i�lll!NNINfdIIINNGNNNIINIIIN!N!iNNINI@NNN8INIINNIIIp11!NG.�II�III�N�NINNNIIII@9NIIgf91 iNNIfG!9"��!NNNN�N��iN4a�l <br />