Laserfiche WebLink
` SAAOAQUIN LOCAL HEALTH DO RICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET — —_--- <br /> ----..............- <br /> _ ._....._. --- --- -- --- --- ---------- FACILITY CONTACT NAME <br /> F FACILITY/SITE NAME <br /> AMr. & Mrs . Wayne Pyburn Mr. Wayne Pyburn <br /> I PHONE 1 Y1TH Amu COOK <br /> SITE <br /> L STREET ADDRESS (209)0869-2889 <br /> I 20851 So_ . Sutliff Rd. _ — <br /> Y CITY -- — Ca. <br /> 91�P3C20j1E JItof,T:nks 1-550 Gallon Tank <br /> Escalon — �'U —_—_.___--- <br /> A APPLICANT/BILLING NAME FOWLICANT <br /> ICANT CONTACT NAME <br /> �' <br /> F Mr. & Mrs. Wa ne Pyburn Wayne Pyburn <br /> L... ._ . �._I MAILING ADDRESS PHONE 1 "TH AREA cave <br /> C 20851 So. Sutlµff Rd. (209) 869-2889 -- — <br /> -- <br /> A- — -- - - --- <br /> --It E ,,77 P pM�F TYPE of APPLICATION <br /> N'CITY y�3�CI claauRe, 1NEIALLAT1eN, ETC. Closure <br /> T Escalon ^ - � � ------- <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T �-198�� _I� — 1988 —i 983 - --• �0 0�— <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks 1 x 150.00 1986 7 1988 19189/ _ <br /> A (multiply_)-by fee for V - o° <br /> C each year applicable) L/ ✓ / ✓ $ %fJ0 <br /> L STATE SURCHARGE _ $56.00 each TANK ( CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) _- <br /> T 1 Tanksf_i/ x $56.00 1386 1987 1986 1383 _ _ <br /> Y (enter amount and year) _ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> _.._..------- <br /> 0 <br /> _ _._0 CLOSURE FEE = $90.00 each TANK 1 Tanks_ f x $30. <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) _ <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks______ x $80.00 f <br /> P PLAN CHECK (Installation or Repair) u ' <br /> _r <br /> N PLAN CHECK FEE $30.00 each Su6MI55i0NrAESJD, ISafG <br /> —__-.._..._._..-- - ----- -- ---_ <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanksx (110.00 $ <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 INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = f30.001hr FEE = f35,001hr FEE _ $35.00/hr f <br /> .....----- - - — —— <br /> TOTAL DUE I e y G — <br /> OFFICE USE ONLY <br /> fl!NImm.NmmmmNNN �ImmImNI�ImP I�719WIN mmm m "fll�illmmflPm,6NINE MIalm�mlml@ml <br /> 40101=0191151 imflmlmNml':iiPiGlifll .ilmnglm29Rm�9PiIImlC9mmlmi 041ilmflflm0111!IP'�Ifl��j <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVCHECK. 1/CASH CVD BY DATE RECEIVED PERMIT 1 <br /> .. _ - - ------- <br /> I �Nqi N� 1 �v ��Nml�i ;m��N mPl!I mlmNNmIN,I�NImIPI N NNmm Nm!mmllli!JNflI@ 1NmfmfmN��0111R110110170005 <br />