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SA JOAQUIN LOCAL HEALTH A TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> ...............­­--------­------ --------- <br /> F FACILITY/SITE NAME <br /> L STREET ADDRESS SITE PHONE # WITH AREA CODE <br /> I <br /> T <br /> I IP CODE I of Tanks <br /> I Of <br /> at Site <br /> Y CITY SATE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS 1APPLICANT PHONE I "IT" AREA cove <br /> A ....... <br /> "F ,�N CITY IIP CODE TYPEf APPLICATIONT <br /> CLOSURE, INSTALLATION, ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ............ ........... .......... ............. --------- <br /> C 1986 1927 1980 1989 <br /> T <br /> I <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> .......... ---------- ........... <br /> F I Tanks x $50.00 1986 1987 1988 1989 <br /> A ( ultipl`�_Fby fee for <br /> C each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK-(see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> I ...... IkA <br /> T I Tanks x $56.00 1986 1987 1980 1389 <br /> Y (enter mount and year) q <br /> C PERMANENT CLOSURE (Remoyal or Closure-in-place) <br /> LL A rk I' <br /> 0 CLOSURE FEE = $90.00 each TANK a n'k� x $20. MCES <br /> SlT <br /> ------- <br /> RJEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x $80.00 $ <br /> ................... <br /> P,PLAN CHECK (Installation or Repair) <br /> A <br /> N PLAN CHECK FEE m $30.00 each SUDKISsION/RESURMISSION <br /> 'REPAIR <br /> P TANK REPAIR FEE = 1110-00 each TANK Tanks x $110.00 <br /> E ....... .............. ........ ................................... <br /> P <br /> ATIPING REPAIR/CLOSUREIREMOVAL (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-.= $'10 00;,l FEE = $35,00/hr <br /> TOTAL DUE <br /> OFFICE USE 081y <br /> RIMPT-119 HUI IT NPgP11T1R!T1!11111il!l 111 NINF100114'Llli,111111 <br /> y P <br /> SWEEPS I COMP 4 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVV BY DATE R CEIVED PERMIT I <br /> ............... ...... <br /> I I FIR <br /> HIP11 I m 0 3 <br /> 166. 01181!fiio��, <br /> 177 VE111117N � .1 <br />