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Ste JOAQUIN LOCAL HEALTH STRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WOR EET <br /> - <br /> . ... - -_ .-. — —--- ----- - <br /> F FACILITY/SITE NAME _ — — FACILITY CONTACT NAME <br /> A <br /> l-- <br /> L STREET ADDRESS SITE PHONE f WITH AREA CODE <br /> Y CITY �- �SI)ATE-ZIP CODE - a of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME - <br /> P <br /> P <br /> L ---- <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CEDE <br /> C <br /> N CITY STAT Z1P'CODE TYPE of APPLICATION <br /> T __--- CLOSURE, INSTALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> _..-----_ <br /> C 1986 1987 1988 1189 <br /> 1 f <br /> V --- _ ----- — <br /> E TANK FEE _ $50.00 each TANK <br /> -._..._.... ..........-. ... ....._.._.... ---._.... _ .. — ---..........._ <br /> F f Tanks x $50.00 1986 1987 1988 1989 <br /> A (EultipTy-i-by fee for _-•------- <br /> C each year applicable) — f <br /> 1 --- --- ---—._.—.__ -- -- —I—. <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH f SAFETY CODE Sec 25287 for applicability)) <br /> -F - <br /> T 1 Tanks x $56.00 1986 1381 1988 1383 g p <br /> Y (enter iiii5it and year) -----•-- --•--------------- R CFEI-.. <br /> f <br /> .-.........-...........--- -_- --- --- —--- <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L..----...- — -_.-......--_-_.._-.._-.-..-._ --_. ----- - -_ -- <br /> 0 CLOSURE FEE _ $90,00 each TANK ! Tanks x $90. <br /> 5...-- --_— — ----__-- ---- ------ IT 5 ($VICES <br /> U -- <br /> P, TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E -- _- .... --- ----- ------ --_— - - - __- -- <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks__ _ _ <br /> x $80.00 f <br /> IP PLAN CHECK (Installation or Repair) <br /> A -------_..._-- _ <br /> -- ......... - ---------- - _.._......-...... <br /> M PLAN CHECK FEE _ (30,00 each SUBMISSION/RESUCMISSION f v <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK f Tanks x $110.00 $ <br /> P . -- -- ----- ---------- -- — ----- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I ...--- ---_._...._-....---...- --- _- -_ _..._..._...---- -.-._. _— ---- — — --.-— <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> _......__.._.._.._......... . - - —_ <br /> FEE = $30.00/hr FEE _ $35.00/hr FEE <br /> TOTAL DUE f "= <br /> OFFICE USE ONLY <br /> NIN!mmN"mNmmNIIImIIImNNpmIIllNiilmmm l!9NINgNrI mNpNNI. IIiNNlhmmmVNufilimNNNCN1 �film.N 1N imm!1m.�llmmli!NN! !mmm!NN1!I IER, m011, 31A NII!II!011PCwTIiI i.11111M RTIP'0 if9mmlm NEI,VNIimN!m�I1NIP,NCIN!0 <br /> SWEEPS f COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RC,VD CHECK 1/CLASH RCVD BY DATE 7RCEIVED PERMIT f <br /> INNm�mNuNNImNmmm,Nl �ii NNINV�� N IINNiII�VIN�I��NNaINIhmIINNNmNNNIINmNNmPININmNV�NII� ''f1mImNIINI mN NNl mmMIVINIINNIINmININIIN NN NN IIIm901119110 N1NNNmmr� <br />