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Jr.rL — 9 -54 WEI) 1 4 : 1 7 MOORE PETROL. EIJ P � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDER6ROUND STOORAOE TANK PROGRAK - FEE VORKSHEET <br /> F FACILITY/SITE NAME _ FACILITY CONTACT NAME <br /> A <br /> C f= r}r11 rc 5 t= X XG,y �Ll1 r- <br /> �Z�?Y ' '�a.z� �.. <br /> ISITE PHONE 1 wrrw A` eooc <br /> L STREET ADDRESS ' 20 - X39 - -27 / 7 <br /> Y CITY -~ ! - -' �.. STAT ZJV CODE it of Tanks <br /> ryG/4 at Site <br /> A APPLICANT/BILLINS NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 wrrw ARRA aaac <br /> r, a. 204) 83 5 -27!;0 ..�.�------ <br /> k CITY .�� STAT �1P°CODE TYPE of APPLICATION <br /> T 8i�►V 1 ew■u■it, erns■r.LAtra■, cTcr /"btlAZ <br /> FACILITY FEE 1100.00 each SITE ADDRESS per YEAR <br /> _-� __— TOTAL._. <br /> A <br /> T 1986 1981 1988 ^1989 _ - <br /> E TANK FEE = 00,00 each,TANK <br /> i 1 Tank s _ z <br /> 110.00 1986 1967 _ 1988 1989 <br /> A caul t i pay_l<_by fee for ------W� "� <br /> C each year applicable) _ 1 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH It SAFETY CODE'Sec 25281 for applicability) <br /> T 1 Tanks - 1 136.00 1986 1981 1988 1989 �- <br /> Y (enter amount and year) <br /> 1 <br /> C PERMANENTCLOSURE (Reiaval or Closure-in-p-in-plate) _ —��-� <br /> 0 CLOSURE FEE = 110.00 each TANK _ E Tank,... 130.00 i a q <br /> 5---- <br /> UT . _. <br /> P. TEMPORARY CLOSURE (Only alloved one time for up to tvo years) _ <br /> TEMPORAPY CLOSURE FEE = 180.04 each TANK t Tanks.. 1 180.00 1 <br /> P PLAN CHICK (initillation or Repan! <br /> A <br /> N PLAN CHECK FEE = 130.40 each SUSNISS1011/RESUEMISSION 1 <br /> REPAIR <br /> F TANK REPAIR-FEE - 1110,00 each TANK ~ I Tanks---- 1 1110.00 --- <br /> F _ hour to be on plan submittal) <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, ,ini;ui one u _ <br /> 9 UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> When applicable) ��. (when applicable) .� Cvhen applicable) --- <br /> FEE -rt30-.00/hrL____.__�_ FEES;35.001hr FEE = $35_00/hr <br /> TOTAL DUE - 1 <br /> VFW USE ONLY <br /> WIT77M ,N :� L.II+M,.r W471. M�4rlaJ�AIAWit 0-R1" <br /> 5�EEP5 1 COMP II LOC CODE CODE AMOUNT DUE AMOUNT RCVD CHECK 1/C °" RCVD OY DATE RECEIVED PERMIT I yL1 <br /> A,k+r,,i. r�; .� �r� _fir . ,:iJS A ° ''�• t :- S5� aW�.'� rlr �dIV)Xs rux,�.. aualfre I <br />