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• SAN OAQUIN LOCAL HEALTH DAICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> Ih�fACILITY/SITE NAME FACILITY CONTACT NAME <br /> f, '7 <br /> L STP,EET ADD; SS SITE PHONE t <br /> � WITH AREA COLE <br /> I <br /> -- �' —1� a _ <br /> Y CITY STAT IIP CODE t of Tanks <br /> � �' at Site / <br /> F APPLICANT/81LL[NG NAME APPLICANT CONTACT NAME <br /> P _ ' I — �- C ___ <br /> I MAILIN 0ORE5 ✓ o G Q <br /> APPLICANT PHONE t WITH AREA co-E <br /> p <br /> S��S= o b <br /> N CITY STAT ZIP'CODE TYPE of APPLICATION <br /> T .'s o L�y CLORURE. INSTALLATION. ETC. ✓� <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> A - --- — TOTAL <br /> C <br /> T 1986 1981 1988 1989 <br /> _ <br /> I _ <br /> V f <br /> E TANK FEE = $50.00 each TANK y <br /> FA Tanks 00 <br /> R . <br /> ( ultipee 1986 1381 1988 19 3 <br /> for <br /> C each year applicable) 9 S <br /> I <br /> L STATE SUP,CHARGE _ $56.00 each TANK (see CA HEALTH b SAFETY CODE Sec 2528) fot appl:i"cabTli!ty); <br /> I - r <br /> 1 1 Tanks z $56.00 — 1981 1987 1988 1983 <br /> Y (enter aiouit and year) <br /> f <br /> I: PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L — _ <br /> 0 CLOSURE FEE _ (90.00 each TANK --� t Tanks � __ x "0.00 S <br /> S <br /> N <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 x $90.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L _ <br /> A <br /> it PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION S <br /> IREPAIR <br /> P, TANK REPAIR FEE _ $110.00 each TANK t Tanks x $110.00 f <br /> E — <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 /> FEE = $30.00/hr FEE _ <br /> ---�.. $35.0hr IEE $35.00/hr <br /> $ <br /> TOTAL DUE f cJ' Q o0 <br /> OFFICE USE ONLY <br /> SWEEPS ! COMP ! LOC CODE DIST CODE AMOUFIT DUE AMOUNT RCVD satCK l/CASH RCVD DY GATE P,ECEiVEO PERMIT ! <br />