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SA J OAQUIN LOCAL HEALTH ATRICT <br /> UNDERGROUND STOWE TANK PROGRAM - FEE WORKSHEET <br /> ��—` J/r �UECl` FACILITY CONTACT NAME <br /> L STREET ADDRESS /} SITE PHONE 1 WITH AREA CODE <br /> T -- T J� 11tif I (/ �U 11 ort D <br /> Y CITY STATE IIP 000E I of Tanks <br /> S'-MQk MA) _ off- at Si to t<sZ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> F U1.i • H C'-arn Ply y War—' C . Q E�Y.lJl7c,IS <br /> L _ <br /> I MAIL�(G ADDRESS — APPLICANT PH HE <br /> i MIrN AREA CODE <br /> A i^f 0 (2�+,6 A �„t}t2C5 f} <br /> N CITY X53 - 2c�ao <br /> T OaAJ�,/ZA STA1 IIP CODE TYPE of APPLICATION <br /> - ---_.� CLOIURE, INSTALLATION, ETC. <br /> JFACILITY FEE = $104,00 each SITE ADD?ESS per YEAR <br /> AI.._..__` — -- ___ _ _ TOTAL <br /> C 1986 1931 1988 1989 R <br /> i <br /> 1 <br /> E TANK FEE = 550.00 each TANK <br /> F I Tanks - x $50.00— --1956 1987 1988 - 198'3 <br /> A (multipTy-1-by fee for <br /> +: each year applicable) — <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> I-- <br /> T I Tanks -x 156.00 1986 1457 1988 1989 <br /> jY (enter eiptint and year) _ <br /> I' <br /> PERMANENT CLOSURE (Removal or Cloture-in-place) � ��-� <br /> L -- _ <br /> 0 CLOSURE FEE = $90.00 each TANK — — <br /> S I Tanks— x 590.00 $ , 0O <br /> - <br /> �P TEMPORARY CLOSUP.E (Only allowed one tine for up to tvo years) <br /> E- <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK JI Tank, _ _ x $94.44_ <br /> �P PLAN CHECK (Installation or Repair) — <br /> A - ----- --_--IN PLAN CHECK, FEE = 130.00 each SUBMISSION/R. SUEM15iI0t1 <br /> IREPAIR <br /> P TAN): FEPAIR FEE = 1110.00 each T0K - ——` - <br /> E,_._.______ 1 Tanks x $110.00 5 <br /> +A PIPING P.EPAIR/CLOSETRE/REMOVAL (Fees are per hour, Iiini.us one hour to be paid on plan subaitta1) - <br /> !�� -�l <br /> �R UNAUTHORIZED PELEASE EVALUATION ICON7rPOCT1ON INSPECTION — -1(when applicable) fwh= SAMPLING INSPECTION <br /> n applicaGlel <br /> _ _ (when applicable) <br /> f FEE _ $30.44/hr FEc = $35.07fhrFEE S25.001hr <br /> TOTAL DUE ; ©D <br /> (?FFFCP' USE ONLY <br /> "�. .' :._ 7T. r <br /> �5�'EEPS I COP'^ f LOC CODE 0CuE AMOUr;T CU; AnOUf{T R(V0 CHcf I/rASH li�.Vb DY DATE PECEIVEO PERMIT I <br /> _. <br /> A��r4fall,I�l� ��I- ,L v Ian ��_ tr�I m a aas - -- <br /> �� iJ4dl Kk� Cq .72%saw�l a a' illw, w �?-.1�x1,,,"�r1lal�9e ��rG'�I�;11r�V1� "q�F i � n ".Epi <br /> l„ kGt� Q UI�I SNINOT OT <br />