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JOAQUIN LOCAL HEALTH D <br /> T R I C T <br /> NDERGROUND STORAGE TANK PROGRAM - FEEgKS <br /> •PAPPLICANT/BILLING <br /> Y/SITE NAME —— /N rj <br /> FACILITY CONTACT NAME <br /> LP( PPA�I� tti �� <br /> DDRESS <br /> ��O�j SITE PHONE 1 (with Area Code) <br /> SRc . <br /> �S+ STATE ZIP CODE # of TANK'S <br /> lBILLING NAMEC4� 952at Site APPLICANT CONTACT NAME <br /> is� -r,�DDRESSOOc i C�)' Qee APPLICANT PHONE # (with Area Code) <br /> `/� Cv�- STATE ZIP CODE TYPE of APPLICATION <br /> A (04, 757G� (Closure, Installation, etc,) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> C <br /> 1986 (987 TOTAL <br /> I <br /> 1988 1989 <br /> V <br /> E TANK FEE _ $50.00 each TANK $ <br /> F t Tanks x $50.00 1986 <br /> A (multipry I-by fee for 1981 1988 199'3 <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE _ $56,00 each TANK (see CA HEALTH f SAFETY CODE Sec 25281 for applicability) $ <br /> I <br /> T # Tanks x $56.00 1986 <br /> Y (enter adount and year) 1981 1988 1989 <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-plate) <br /> L <br /> O CLOSURE FEE _ $90,00 each TANK <br /> S 1 Tanks_-(-- x $90.00 $ (� <br /> U -IG- Oo <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK <br /> # Tanksx (80.00 f <br /> P PLAN CHECK (Installati <br /> L on or Repair) <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> jOq f <br /> REPAIR <br /> R <br /> P TANK REPAIR FEE _ $110.00 each TANK <br /> A # Tanks_ 110.00 U $ <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION <br /> (when applicable) INSPECTION SAMPLING <br /> INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr <br /> FEE _ $35,00/hr $ <br /> OFFICE USE ONLY TOTAL DUE $ q0 OU <br /> SWEEPS t COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT kCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> "NN } <br />