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SAN JnAQUIN LOCAL HEALTH DISTRICT <br /> U%vK6ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A & PAYMENT <br /> I <br /> L STREET ADDRE/9S. SITE PHONE I (with Area Code) <br /> I 5'a T,volus�r/c� QY'. Qaa <br /> r <br /> Y CITYVx / q�N Si�E IIP CODE I of TANK'S <br /> �+'J` '7 at Site ENVIRONMENTAL HFAI TW <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME PERMITISERVICES <br /> P <br /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE I (with Area Code) <br /> C <br /> A <br /> N CITY STATE IIP CODE TYPE of APPLICATION <br /> T (Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T <br /> I $ <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks _ x $50.00 1986 1987 -I 1988 �/ 1989 j <br /> A (multiply i by fee for cz d� 00 <br /> C each year applicable) � (� d s� f �� <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanksx $56.00 1986 1987 1988 1989 <br /> Y (enter auount and year) as <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK I Tanks x $90.00 f <br /> S <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 I Tanks x 180.00 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 /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK 71 Tanks x (110.00 1 <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr IFEE _ $35.00/hr is <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVOCHET I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> z aN« y20 Zss ° ° 25� -64 s si <br />