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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> • • 4 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> . <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> I <br /> ' I ,L 1 _ U r.l _ <br /> S <br /> -C_ p <br /> L STREET ADDRESSSITE PHONE I WITH AREA CODE <br /> I <br /> Y CITY STATE TIP CODE t of Tanks <br /> — at Si ke ` <br /> A APPLICANT/BILLING NAME - APPLICANT CONTACT NAME <br /> P <br /> 1 MAILING ADDRESS' r APPLICANTITPPHON I WIIT,H�AREA CO/DE <br /> -- � L✓"7 Ci `_�l�D� <br /> N CITY STATE ZIP CODETYPE of APPLICATION GLcJ <br /> T � . I 31 c? -: TCLOSURE• INSTALLATION, ETC. <br /> FACILITY FEE _ $100,00 each SITE ADDRESS per YEAR ------�..._------ --- —__ TOTAL'- <br /> T -- ..-. - -- -- _-__ .__ - - _,_ ._._._.__..,.__._._------- - - _ _ __- <br /> �+_._-_-----.---__.___,_._.____.._._.-._. 1986 1981 1388 1589 <br /> I $ <br /> E TANK FEE = S50.00 each TANK - <br /> F I Tanks _� x $50.00 1986 1987 6388 1983 <br /> A (multiply-ii-by 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 - - _- ------- -.__ - -- ----- -- - - - <br /> T 1 Tanks 3 x $56.00 1386 1387 1988 1989 <br /> Y (enter a-a6u-nt and year) ---- ----•- -_------ — __ ___--._____- ---- - <br /> C PERMANENT CLOSUREp(Reaoval or Closure-in-place) -~ -�- - ----- -- <br /> --- <br /> D CLOSURE FEE = S'30.00 each TANK —_� I Tanks -� x $30.00 --� S --- 27� �o <br /> 1) --- --------_ - --_ _ -- _ -w . _ - -__ r <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) _ — <br /> E ---- <br /> TEMPORARY CLOSURE FEE = $80.00-each TANK -_-------___# Tanks-__..__._ x '$80.00 <br /> P PLAN CHECK (Installation or Repair) <br /> L-------- --- <br /> I11 PLAN CHECK FEE = $30.00 each SUBMISSIONIRESUDMISSI011---- _ ---__ -- _S -- - <br /> REPAIR <br /> R TANK REPAIR FEE = S110.00 each TANK IS Tanks x $110,00 ; <br /> E <br /> P -- <br /> A PIPING REPAIR/CLOSUREIREMOVAL (Fees are per h4Ur, 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 = 530.00/hr FEE = $35.00/hr F€E = 535.00/hrl S <br /> - ---... _.......- __-_ ............. <br /> TOTAL DUE <br /> OFFICE USE ONLY - <br /> �I!'.lII�II���QII!'orf[�I�E!IRll;itnll>��!�!i{tills!.�i�?191I{I��liln�l!igli�! III!���!fipl��'I�il�'i�l!pP�iiiwG�!ill�illl��iIEIIP���"���laJ�al�!ll�l!!I�II�f fli{Ilii!�I�h�l�ll�nll�Illii�llliiliiliil�l{ill�'�,iufi1lini i�,�ll�il�lll;`pi�iFlil�llG!I�I�IIII!I���I'��'�i�IiIIIQlG9�E�I�'dRI�N!I <br /> SWEEPS I COMP k LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK <br /> . I.I_...I.Ii.� . „ ., � ._......................__............._.._ _..._..._.. ......_ _.. --t/ClASi <br /> H� RCVD--BY_... DATE" RECEIVEDPERMIT t <br /> ........._._ _..............._ <br /> i11 1 � !�M1,1111. SIlio� �I� �111..1!�� r I!Gq� ��� <br />