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SAN JOAQUIN LOCAL HEALTH DISTRICT UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET F FACILITY/SITE NAME - —^ *FAC NAME ` H ARCA CGmm STREET ADDRESS_ /T STATY CITY A APPLICANT/BILLING NAME APPLICANT CONTACT NAME P AP 1 MAILING ADDRESSICANT PHONE 1 WITH '""AR co"' !� � N CITY STAT L P CODE APPLICATION T CLRRYR! PLICATIOImN. LTC. _ 1 --- -�_ TOTAL FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR —^ -- - —_---,- - - -- C 1986 1987 1968 1583 T 1- 00 v 1_ E TANK FEE _ $50.00 each TANK - F 1 Tanks Z z 150.00 1986 1381 1988 1989 A (eultipTY f by fee for C each year appluable) — y-p �O �a7 S�JC I — L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) 18 1983 --- T-1 Tanks j__ x $56.00 1986 1987 198Oo Y (enter amount and year)^� 57 C PERMANENT CLOSURE (Removal or Closure-in-place) L ---------- t Tanks_/ _ x 190.00 0 CLOSURE FEE _ $90.00 each TANK _ S - U. — -- �� R TEMPORARY CLOSURE (Only allowed one time for up to two years) -, !� - E 1 Tanks x $80.00 f TEMPORARY CLOSURE FEE = $80.00 each TANK �—- -----_ - P PLAN CHECK (Installation or Repair) _ _-------- L ------- -- - A 1 A PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUDMISSION EPAIR - _----- ---- f F. TANK, AIR FEE _ $110.00 each TANK 1 Tanks______ x $110.00 _-- E -,._._..- -- --_ - --- — - --- P._...._ A PIPING REPAIR/C RE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan subm:tal) R UNAUTHORIZED RELEASE E AiION CONSTRUCTION INSPECTION Svhenlapplicable)GlON (when applicable) (when applicable) ---- - _—_ ........_. ..------------ - FEE = 135.00/hr FEE _ $30.00/hr FEE = f35.00/hr -- ___ ____-h-.._—.._---- ---- --- -- _-- - TOTAL DUE f -7Y(2 Z OFFICE USE ONLY SN LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVB CHEC. /CASH KCVO BY DATE RECEIVED PERMIT t 6 7�i6 -rNc-amu � 9� �.