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OJOAQUIN LOCAL HEALTHOSTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME— -- — — -— FACILITY CONTACT NAME <br /> A <br /> I - --" WITH AREA COOE- <br /> L STREET ADDRESS SITE PHONE I <br /> T _ —_l l3.> __��LV �q _— -- <br /> STATE IIP CODE I of Tanks <br /> Y CITY at Site <br /> TLICANT - <br /> A APPLICANT/BILLING NAME CONTACT NAME <br /> P <br /> P v/ _ <br /> L._._-._-.. - 5�.....-.-_._..- ___ YITX AREA CODE <br /> I MAILING ADDRESS LICANT PHONE 1 <br /> A — — - --^! STATE IIP CODE TYPE of APPLICATION <br /> N CITY CLOSURE, INSTALLATION, ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A _ — - - -- <br /> C 986 —0D7 19j C�0 --1989 <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks x $50.00 1986 1387 1988 1989 <br /> A (multiply-1-by fee for _ m <br /> C each year applicable) _ � — $ Z <br /> 1_______ _ 1- _ _ _ - <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks 1 $56.00 1386 —1987 1988 1989 <br /> Y (enter iiouit and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) _ <br /> 0 CLOSURE FEE = $90.00 each TANK _^ -$ Tanks______ z $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 = $00.00 each TANK TI Tanksz $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L...._._._—_____._._—.--_�_—_._.__...---.----_— <br /> A <br /> N PLAN CHECK FEET= $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R TANK, REPAIR FEE = $110.00 each TANK 1 Tank ^: x $110.00 <br /> E- <br /> _—_ <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 CONSTRUCTIONINSPECTIONSAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE =Yf30�00/hr1._..-_.______—__ FEE = f35�00/hr — FEE=f35.00/hr --�— <br /> TOTAL DUE f 1, <br /> OFFICE USE ONLY <br /> GIIG,G!G@:G@I!I000G!G�I AGGGIIIPINIGI!GIGGf��'mIGGGGGl1lGIGI9I I@ 1flIIGGI�G@IUGGGiGa�GIGGIIGIGi"GIGIG!GIIIGG1G1GG!!�II.�IIGGGG�I!!IGIP,IV�GIIflG I!II:"GGa1G1lI;I�GIIGG00011iGIGl1�,IGG�GIGIG^I':„PuGIiGI�GGiiGGGIG!GCG!iGilliIIGGGGGGIGGI!G IGG@G.�I!GI!GIIGI91GGilf!MIIIG1GG�j <br /> P LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> �''�G� GI�.��' � � �GGGI!IIGNIIGIII��I@,IG911GIIGG111!'III000IIG I!��GII�tIIIG'GIGII�I�IIGV91iIIGllll IIGiIIIIGGGGGIIII�IIGGGGIIIVIIGGI@GIGV�IIIGGGGIIi,I�I�II�IGIIIIIIG�IGII�!GGGGG9I .IGIIIIGGiGSERUM1a� <br />