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SAjbJOAQUIN LOCAL HEALTHTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORK <br /> AGILITY/SITE NAME FACILITY CONTACT NAME <br /> C <br /> I <br /> L STREET ADDRESS <br /> 1 SITE PHONE I (with Area Code) <br /> 3 J �eeSh r n <br /> T <br /> Y CITY STATE ZIP CODE I of TANK'S <br /> at Site <br /> A APPLICANT/BILLING NAME <br /> F APPLICANT CONTACT NAME <br /> P <br /> L <br /> 1 MAILING ADDRESS <br /> C APPLICANT PHONE f (with Area Code) <br /> A <br /> N CITY STATE ZIP CODE <br /> T TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR —i <br /> A TOTAL <br /> C 1586 <br /> T 191 1,388 158'3 <br /> I � J <br /> V U OZ� 4 �. <br /> E TANK FEE _ $50.00 each TANK j <br /> F I Tanks z $50.00 1986 1581 1588 1539 <br /> A (multipri i by fee for <br /> C esl, ; :,; alipiicshle) <br /> I � <br /> L STATE SURCHARGE _ $56.00 each TANK, (see CA HEALTH & SAFETY CODE Sec 25281 for applicability) <br /> I <br /> T I Tanks z $56.00 yea 1586 1581 1988 1985 <br /> Y (enter auount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> O CLOSURE FEE _ $90.00 each TANK I Tanks x $50.00 <br /> 5 $ <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK I Tanks x $80.00 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A _ <br /> N PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUBMISSION <br /> $ <br /> R REPAIR <br /> E TANK REPAIR FEE _ $110.00 each TANK I Tanks x 1110.00 <br /> P $ <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, <br /> R minimum one hour to be paid an plan submittal) <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35,00/hr <br /> $ <br /> f O <br /> OFFICE USE ONLY TOTAL DUE <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK /CASH RCVD BY DATE RECEIVED PERMIT I <br /> 1814 <br />