Laserfiche WebLink
SAOJOAQUIN LOCAL HEALTH 10TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C U/UCLLr = &c-, P. " <br /> i <br /> ISTREET ADDRESSSITE PHONeI WITH AREA coos <br /> T __30z w-'� _- <br /> Y CITY STATE ZIP CODE aSte <br /> Ot of Tanks RECEIVED <br /> __ i <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME JAN <br /> P _ <br /> P __S C h ea Cin <br /> L---- �nx — ..._.—__� A.NVIRQNIM€N�'hE H64TI i - <br /> 1 MAILING ADDRESS — - APPLICANT PHONE 1 WITH Mf?fSERVICES <br /> C: <br /> A — <br /> N CITY STATE ZIP CODE TYPE•of APPLICATION T- <br /> T oeuec, IWernuenoN, erc. ' <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A .. ---- a_ - <br /> _ _ —.... .87 1909 <br /> y-. U6 19 - --- _-1389 f— O <br /> E TANK FEE _ $50.00 each TANK <br /> -- <br /> F I Tanks j s $50.00 1987 1988 1909 <br /> A (multipTy 1-by fee for — 4 <br /> C each year applicable) Eu $ <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 5 SAFETY CODE Sec 25287 for applicability) <br /> ( — — --- - — <br /> T I Tanks ( x $56.00 ± 1186 <br /> 1987 1988 1989 <br /> Y (enter ziount and year) --- - -_ S 6 <br /> l $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L - <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks x 130.00 $ <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 1 Tanks x (80.00 f <br /> P PLAN CHECK (Installation or Repair) -- — <br /> A <br /> H PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION $ <br /> .._ 'REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK $ Tanks - x $110.00_— — $- -- -- <br /> --- - <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 = f30.00/hr FEE _ (35.00/hr FEE <br /> TOTAL DUE f 69 5-6 , 00 <br /> OFFICE USE ONLY <br /> 111IflP1!' 11�111@flIR1111991�11.�1111Pm1!P@9999 . i.l@! �111i91911 TIMI :i X111! 11�1IRR TdE .f11�11111fl9111111i1111 l�ll�fl!1 Ml.�li�1ll�flf^',1111111. <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK. 1/CASH KCVO BY DATE RECEIVED PERMIT 1 <br /> �: ..• IDD D I' � 1 ......_......................_.x.__............ 111111@1111. 11 CI........I'" . 1 <br /> T o. a 3 65600 .._._...._....._.._.. -.._.._.__.._ <br /> � w <br /> N1 1.R�v �lG�19!1111!1191@1fi!111a111911i!I, I I� 1111 m111"111�1�111111111i1 @f1C11p1�1111�11. i 9111191V 111111111111111111911111..91 .111,1111.Q@I11111�19111111111u <br />