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.auAuuliv LULAL HEALTH DISI-RICI- <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> f (AGILITY/SITE NAME FACILITY CONTACT NAME <br /> A 1 <br /> I r- r C— <br /> L <br /> L STREET ADDRESS SIZE PHONE t <br /> WITH ^[[A cm0[ <br /> Y CITY STA1 ZIP CODE 1 of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L AYMFiyr <br /> I MAILING AOORRECE�VED APPLICANT PHONE 1 <br /> WITH •N[• COD[ <br /> G <br /> LFY STAT ZIP CODE TYPE of APPLICATION <br /> SAN JOAQUIN COUNTY INmTALL.9104. [TC. <br /> fAClll( = tl b. eaih <br /> AMIT DRESS per YEAR TOTAL <br /> A <br /> C 1986 1901 1988 1989 lc�cll? <br /> I <br /> I <br /> V C' b �Z?C) i <br /> TJO \ o(=, \ �C� 1 <br /> E TANK FEE [ $50.00 each TANK <br /> F 1 Tanks s_ x $50.00 1906 1987 1988 1989 c Cj <br /> A (aultlpfy I by fee for <br /> C each year applicable) - SO <br /> <— <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH L SAFETY CODE Set 25287 for applicability) <br /> 1 <br /> T 1 Tanks,5- x 1156.00 1986 1981 1988 1909 <br /> Y (enter amount and year) <br /> a�O.�� <br /> Ej <br /> CLOSURE (Removal or Closure-in-place) <br /> E c 190.00 each TANK 1 anks _ Y 190.00LOSURE (Only allowed one time for up to two years) <br /> LOSURE FEE - 180.00 each TANK 1 tanks x $ <br /> 80.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE • $30.00 each SUBMISSION/RESUBMISSION 1 <br /> REPAIR <br /> R TANK REPAIR FEE [ 1110.00 each TANK <br /> E t Tanks _ x 1110.00 1 <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 INSPECTIONjMPLING INSPECTION <br /> (When applicable) (when applicable) hen applicable) <br /> fEE _ $30.00/hr FCE = 135.00/hr E - 195.00/hr 1 <br /> TOTAL DUE 1D O a <br /> Orr)CE USE ONLY <br /> FS4EEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT!R7CVC.XCCASH RCVD BY DATE RCCEIVED PCRMIT 1 <br /> " 6 Xu xtl II I q' ''n <br /> ` , <br />