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SO JOAQUIN LOCAL HEALTH • STRICT <br />UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET t% I <br />F <br />FACILITY/SITE NAME — <br />FACILITY CONTACT NAME <br />A <br />r, <br />f <br />TOTAL <br />A <br />L <br />STREET ADDRESS <br />SITE PHONE I WITH AAEA CODE <br />I <br />T <br />TEMPORARY CLOSURE (Only allowed one lime for up to two years) <br />$ <br />Y <br />CITY 7 <br />STATE <br />ZIP CODE <br />1 of Tanks <br />R UNAUTHORIZED RELEASE EVALUATION f.OHSTRUCT(ON <br />(when applicable) — Ivhen <br />FEE _ {00.00/hr — FEE _ <br />— ISN SS•' t✓1 �Ictw <br />SAMPLING RISPCCTION <br />Ivhen applicable) <br />FEE - 105.00/hr <br />— �_._� <br />{ <br />at Site <br />A <br />APPLICANT/BILLING NA E <br />APPLICANT CONTACT ME <br />� Gli+�c,e1 h i <br />1 <br />A <br />MAIL ADDRESS— J 1; 5 S fl'k/1 <br />L—j I <br />ONE I WITH A... COOK <br />APPL Ni PPW <br />N <br />CITY �) <br />STATE <br />ZIP'CODE TYPE f APPLICATION <br />F <br />A <br />1 Tanks c t50.00 `1906 1997 <br />leach yea -1 by fee for <br />—� <br />/ <br />ctosunE. INSTALLATION. ETC. <br />C <br />FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br />0 <br />S <br />TOTAL <br />A <br />— --- <br />U• <br />- <br />R <br />E <br />TEMPORARY CLOSURE (Only allowed one lime for up to two years) <br />$ <br />1706 <br />1907 <br />1700 <br />1703 <br />R UNAUTHORIZED RELEASE EVALUATION f.OHSTRUCT(ON <br />(when applicable) — Ivhen <br />FEE _ {00.00/hr — FEE _ <br />INSPECTION <br />applicable) <br />$75.09/hr <br />SAMPLING RISPCCTION <br />Ivhen applicable) <br />FEE - 105.00/hr <br />— �_._� <br />{ <br />TOTAL DUE <br />1 <br />V <br />E <br />TANK FEE a 150.00 each TANK <br />F <br />A <br />1 Tanks c t50.00 `1906 1997 <br />leach yea -1 by fee for <br />—� <br />1900 <br />1909 <br />C <br />each year applicable) <br />e) <br />1 <br />L <br />I-- <br />STATE SURCHARGE = 156.00 each TANK (see CA HEALTH I, SAFETY CODE Sec 25207 for applicability) <br />T <br />— <br />1 Tanks 1156.00 1906611307 <br />1300 <br />1307 <br />Y <br />(enter aiounl and year) <br />Il <br />t <br />C <br />PERMANENT CLOSURE (Removal or Closure -in-place) <br />0 <br />S <br />CLOSURE FEE _ $30.00 each TANK <br />1 Tanks s $30.09 <br />$ <br />U• <br />- <br />R <br />E <br />TEMPORARY CLOSURE (Only allowed one lime for up to two years) <br />$ <br />TEMPORARY CLOSURE CCE _ $00.00 each TANK, <br />I Tanks 100.00 <br />_ <br />f <br />P <br />PLAN CHECK (Installation or Repair) <br />L <br />P TANK REPAIR FEE _ 1110.00 each TANK <br />A <br />1 1110.00 <br />- <br />II <br />PLAN CHECK FEE = 100.00 each SU0MISSIOH/RESUDM155f01I <br />$ <br />REPAIR <br />P TANK REPAIR FEE _ 1110.00 each TANK <br />1 Tanks <br />1 1110.00 <br />$ <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are <br />per hour, minimum one hour to be <br />paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION f.OHSTRUCT(ON <br />(when applicable) — Ivhen <br />FEE _ {00.00/hr — FEE _ <br />INSPECTION <br />applicable) <br />$75.09/hr <br />SAMPLING RISPCCTION <br />Ivhen applicable) <br />FEE - 105.00/hr <br />— �_._� <br />{ <br />TOTAL DUE <br />1 <br />0111cl. usE UNIT <br />5WEEPS 1 I COMP 1 ILOC CODEIDIST CODEI AMOUNT DUE I AMOUNT Rr,VO I CHECK WASH I RCVD BY I DATE RECEIVED PERMIT I <br />