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SAN JOAQUIN LOCAL HEALTH DIOICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> --- _-_ FACILITY CONTACT NAME <br /> F FACILITY/SITE NAME Mr. Wayne Pyburn <br /> A Mr. & Mrs. Wayne Pyburn <br /> C -- <br /> I ---" - - - SITE PHONE 1 wITN AREA coos <br /> L STREET ADDRESS O (209) 869-2889 <br /> 1 20851 So. Sutl>µff Rd. _ _ _ _ — <br /> T'- ----- STATE 71P C0 E 1 of Tanks 1-550 Gallon Tank <br /> Y CITY Ca 953F28 at 8rte -___- <br /> Escalon -- -------- - - ----- --- <br /> A APPLICANT/BILLING NAME <br /> APPLICANT CONTACT NAME <br /> P Wayne Pyburn <br /> P Mr. -_&_-Mrs. Wa ne P burn -- •- - ----- -- <br /> L ------ ' '-- �- - APPLICANT PHONE 1 MIT. AREA coos <br /> 1 MAILING ADDRESS (209) 869-2889 <br /> C 20851 So. Sutlµff Rd. _ _ _..-_. -.----•-- - <br /> A- .._-_..__-__.----.----- �yTT p� TYPE of APPLICATION <br /> N CITY S`g }�P3�@� cLGOURE. INETALIATION. ETc. Closure <br /> T Escalon - .---�-- — - - - <br /> --- - NOTAL <br /> Iq FACILITY FEE = $100.00 each SITE ADDRESSP er YEAR <br /> C 1986 -��✓i 19 [989 - -- -oo--'-� <br /> E TANK FEE = $50.00 each TANK ✓ <br /> ----- .._..._......_..._--..... <br /> ----...._ .._..._.._... - .. . - -.. -.-- <br /> . -- __....._._....._._. <br /> 1988 j I 1909; <br /> F t Tanks _-1-by <br /> _ x 150.00 1986 7 �f fl - <br /> A 4ultiply 1 by fee for 1 C%0 n! <br /> C each year applicable) ✓ - ✓ -�__-_— 7 <br /> _ ----- <br /> L STATE SURCHARGE = 156.00 each TANK ( CA HEALTH 4 SAFETY CODE Sec 25287 for applicability)-- _ - <br /> T 1 Tanks]_1/ x 156.00 1986 1907 1988 <br /> Y (enter amount and year) <br /> ---------------..........._._..------._.. <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) ---- <br /> L ------- ._._..-_....._...._ ..-.... --_ -_- _- - Tanks <br /> 1 x 190.0 1 D <br /> 0 CLOSURE FEE = 190.00 each TANK --- <br /> -__ .--1------- <br /> S --- ----- -.-._.. -- --- ---- ------ - <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) - <br /> E------------------•-------- - � 1 <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks------ x (80.00 <br /> P PLAN CHECK (Installation or Repair) <br /> L ---- - _.-.- <br /> A t <br /> tI'PLAN CHECK FEE _ $30.00 each SUBMISSiONIRESUBMISSIOii <br /> REPAIR <br /> R TANK, REPAIR FEE : 1110.00 each TANK x (110.00 1 <br /> E- <br /> P......._.......__.._-_....._......_..-.._..___ ....- ----.- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) - - _ - -----,- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IIISPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00lhr( FEE = 135.00/hrI FEE = 135.00/hr <br /> _.._..........................................-_—_._ —__ -- -—...._._.._- -- --- ...TOTAL DUE 1 / <br /> OFFICE USE ONLY <br /> HIM I <br /> IWQQNQQN!VNINMI4.QV QN94QINNN�11Q1NNPQ@lV@GNflGflIQNQNCQ'a;VQQN!I'NII9Nflflfl."lGf,NWAG�I,alllQQp;';, IIG�GIIGIINQP1111QIQiQ.II'd@Illlf�J!'dfuGlQlfliGNQIINN2NNV!'V4.IQIIIQ�PMQI�IIP N@NmNlll!QIIQQNGNiICti�IQGQgj <br /> 2.�I " ; , oil .... .L.L.I V — IIQIINi I�!NQNpQQI iIIIQNQN1Qu9NIIVlINQ 1 .. <br /> SWEEPS I COMP I L 0 C CODE 81ST CODE AMOUIIT DUE AMOUNT RCVO CHEFK UTASN Rf,VD DY GATE .ECEIVEO PERMI <br /> F pN�7flQ� ��Q 1V ��1QVQiq1Imp.Til!liIQGI�V�T IIIIflgIICd�N.18QQItQIVI II!II�II�QVQI!MI91!II;tN4 !QINVII IQ�+�NI�NQIJ.INIV QQQQQ�IQQQNQQ Q�ILQVQIIIII I ,.IQm�IINMII IIN <br />