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L <br /> S* JOAQUIN LOCAL HEALTH DISTRICT 17_. <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE VORKSHEET <br /> F fACILITYISITE NAVE <br /> h FACILITY CONTACT NAME <br /> 1 �ll �� j�} <br /> Ci Iry ! 4PHONE _ <br /> L STREET ADDRESS�f� SITE Y CI STATE 1IP CODE ks <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I MAILING QDP.ESS <br /> CAPPLICANt P ONE 1 MI►II AR[A coos <br /> `' _— 1 � ,�1 ', L �'! l <br /> N CIT N- 2!iw <br /> ZIP' PLICATION <br /> M//ALLATIOMJ [TC. <br /> FACILITYFEE = 1100.00 each SITE ADDRESS per YEAR <br /> A .___.___,___ ..__ __ � TOTAL <br /> C 1986 1981 -...1488 <br /> r 1483 <br /> V <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanksr 15000 Y. 1486 � I981 — ~ 1988 _-1983 — — <br /> A (multiply'i-by fee for <br /> ( each year applicable) <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH H 6 SAFETY CODE'Sec 25281 for applicability) <br /> T I Tanks x 156.04 1986 TM1987 1988 1303 <br /> Y (enter N665t and year) -- <br /> r PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L - <br /> 4 CLOSURE FEE = 110,00 each TANK 1 Tanks_ x 590,44 1 <br /> R TEMPORARY CLOSURE (Only alloyed one lire for up to Wo years) - <br /> E <br /> TEMPORARY CLOSURE FEE - 180.00 each TANY. 1 Tanks _ x 190.00 1� <br /> P PLAN CHECK (Installation or Repair) PAYMENT <br /> 11 PLAN CHECK FEE 2 130,00 each SUBNISSION/RESIIDNISSION <br /> REPAIR �EJE3,LIC <br /> F. TANK REPAIR FEE - i 110.40 <br /> each TANKT ..1_Tanks------ <br /> x 111O.W1, 1 <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 IIISPECTION <br /> (vhen applicable) _ - Wien applicable} (Y-hen applicable) <br /> fEE� 130.00/hr� FEE - 135.04/hr FEE - 135.00/hr <br /> TOTAL DUE <br /> P1 1 <br /> 1�q�gOFTIICCE us[ ONIr <br /> ,11 lis�UlllE'L�N d �� 9d'W0741IS0 IIJ IIC�. , MIN IIIN• INNIIIFOR p NM.- MR-11111 11111M, WiN 115M <br /> SNEEF5 1 COMP 1 LOC CODE DISI GOOF AMOUIIT DUE AMOUNT RCVO CHECK 16rCASN RryD DY DA1E RECEIVED PZ <br /> Awl ..._ 6U <br /> Pella <br /> �� <br />