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SAM JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> RT-'-F FACILITY/SITE NAME - <br /> ----- _–.__._ _—,_---_.___.-- FAN1 IiY f(IN TACT_JIdtlF <br /> �2R ck� 104C. 1 t C©sr ►>" Na <br /> L STRE T ADDRESS SITE PHONE 1 wITM ARCA coos <br /> o4Z E. k� NE 209 -334-2732 <br /> Y CITY ��, i IIP CODE t of Tanks <br /> --• 95,746) at site �� <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> l3REA AGKIG't�L?URAL . KVIcE Ik1C kogr imer" <br /> I MAILING AODR S APPLICANT PHONE 1 YIr" ARCA CODC <br /> N CIT -Tl�� �/�s� TA ZIP CODE TYPE of APPLICATION <br /> 1 l(/�-/\'y—��_ CLDDURE. INRTALLATION. are. � Mev <br /> .--__-. <br /> A FACILITY FEE`f100.00 each SITE ADDRESS per—YEAR_ _ TOTAL <br /> C 1986 1987 1988 - — 1989 <br /> 1 <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks x $50.00 ' 1986 — 1381 1988 — 1989 <br /> A (multipTy I by fee for ----- — <br /> Ieach year applicable) $ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> T 1 Tanks x $56.00 1986 1987 1988 1983 <br /> Y (enter aiount and year)--- —�--� <br /> t <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) __ — <br /> 0 CLOSURE FEE = $90.00 each TANK 1 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 t Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) — <br /> n _—_-- -- _—.— —-- -- -- - ----- <br /> M PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION f .3D•OD <br /> F TANK REPAIR FEE = $110.00 each TANK — f Tanks z $1(0.00 $ <br /> E --.— --------_..— _.._._.__r- —.-- <br /> P ......---- ---- _ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = f30.00lhrt — FEE _ $35.00/hr _ --- FEE�f35.0 1hhr <br /> TOTAL DUE $ �� <br /> OFFICE USE ONLY <br /> iN!194!111911919.9111 11911119V1!AI1HI!Il4'ORION iUl10110118118 EN4�9�!�gC�, '1101-0301,111111M. 1.11 11T.EiNN-F? QVEMER, ulwsu9'Jm.gB <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br /> _ __._.._...._.._.._......__.............._._.........--- <br /> �'I�1!!luiil�i iC!1m,Pnn' �11Vf9 ��'N1! gi11�JINV1111110VG !!991111911!191i119FiT!IIM9111�911111i9919119�G91ii!11111!1liflllllfl!111111911ii!1191 Ii19il!1911111991@IIIIIIIIII!1GIIIIIVIL1111NIIIf1Vl!iIJV11!1111.IN111111111111111i1111i11111!11V1�11 IiIV!III�1G1ii91�111V111PVl��llllly <br />