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SAN`JOAQUIN LOCAL HEALTH DTS�TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> A ' <br /> FACILITY/SITE NAME — FACILITY CONTACT NAM fl �� <br /> C Ute/ -� - - <br /> L STREET ADDRESS /n 33 SITE PHONE 1 YITM Axa*2000L `•�� <br /> [ ff <br /> T � <br /> Y CITY STATO IIP CODE1 of Tanks ' 9 <br /> �/FfEX�fS at Site <br /> P APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME-- <br /> P <br /> L <br /> C MAILING ADDRESS p O 7i APPLICANT PHONE 1 WITH ARCA Cane <br /> N CITY — S�TAATO IIP CODE T APPLICATION <br /> T Zcue I!QAJ. 52.3 osu INSTALLATION, ETC. <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 1986 1987 — 1908 <br /> I <br /> _ - OU $ U _ <br /> E TANK FEE _ $50.00 each TANK <br /> F Tanks x $50.00 1986 1987 1908 1989 <br /> 1 <br /> A (multiply ('by fee for <br /> each year applicable) T.--J--.- aZ(J(J� '200 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFET11Y CODE Sec 25287 for applicability) <br /> I - <br /> T 1 Tanks x $56,00 1986 1987 1988 1983 <br /> Y (enter iioiit and year) <br /> t <br /> L PERMANENT CLOSURE (Removal or Closure-in-place) -- <br /> 8 CLOSURE FEE _ $90.00 each TANK 1 Tanksx $90.00 $ <br /> U '--- — <br /> R 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 /> PPLAN CHECK (Installation or Repair) — ---- <br /> A <br /> fI PLAN CHECK FEE _ $30.00 each SUBMISSIONIRESUDMISSIOH $ <br /> ^ REPAIR - <br /> P. TANK REPAIR FEE _ $110.00 each TANK $ Tanks x $110.00 t <br /> E <br /> P — <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 ----� ---— — - -— <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTIOq <br /> MPLING INSPECTION <br /> (when applicable) (when applicable) hen applicable) <br /> FEE = $30.00/hr FEE = $35.00/hr .00/hr_.lam <br /> TOTAL DUE f p� <br /> OFFICE USE OBLY — - <br /> P' G"�GG�5V9VVnV0VV!141i`Uif11R IIGVGGPi;GViI0@J011N IEGVIEEG��9119� rG!IGIVI�WI!VVI+IIVIVIV"ylVGui!IIVVG9':IiGGIiIuIGV��MIGIIIV9VV!GGVVGVIfVOGVIIIV �IGI!�V!�IIGING�!IC+JmIGGGV�� <br /> —— <br /> SNEEPS COMP 1 LOC CODE DIST CO DE AMOUNT DUE AMOUNT RCVD CHECK I/ ASH I RCVD BY DATE RECEIVED PERMIT 1 hi <br /> 1 <br /> _ o% ..� - .. —...--... ---- <br /> "!'E 1�71 r^I Em N�VI!,I!!I IILENIEEiI!�Illi fIE!!II!II II E I !l"!!GIIE�111111'"�iIEEE�7 GIiEEilil I!ERI�EIIVV�W1Nl�ll!Vl@i �l!PIEIEG!EEI!RQ.IIEE�IIfVllllllllll!E1iIIlE111G1111411E1J119 LfV�1!VRIIVI �iIIIIE!IEE!lu�� <br />