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IF[FACILITY/SITE NAMECLP,EEi ADDRESS <br />Y PITY <br />SAN JOAQUIN LOCAL H'I_ALTH DISTRICT l� <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACILITY CONTACT NAME <br />SITE Pl6OHE I k1T11 AREA taea <br />STA IIS BE �tQSi#enk� <br />A APPLICANUD ILLING NAME <br />P APPLICANT CONTACT HAVE - -- <br />LNC �'',+/'I✓� �/�j`I✓�� <br />I MAILING ADDRESS �"--- APPLICANT PHONE I <br />T CITY STATE TIP CODE TYPE of APPLICATION <br />�'' G4alWAL# INITAWLATIGN. [TC. <br />�A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br />C --- -. _ _-�TOTAL --- <br />r 1906 1931 <br />E TANK FEE r 150,00 each TANK -' <br />F I Tants <br />A (Iultillfi Tby lee for <br />r <br />ach year applicable) <br />TE SURCHARGE - 156.00 each TANK (see CA HEALTH t SAFETY CODE Set 25201 for applicability) <br />anks $56.00 1996 6981 1'300ter Mount and year) <br />�.'FPI.UANT CLOSURE (Removal or Closure-in-plate) <br />L <br />O CLOSURE FEE t 190.00 each TANK ----------- <br />S TanksU P ARY CLOSURE (Only allowed one line for up to two years) <br />E _ _ <br />TEMPORARY CLOSURE FEE z180,00 each TANKI Tanks <br />_ 1 <br />P PLAN CN£CK (Installation or Repair)_ <br />_--?tiAN JOAQUifq !moi •f i <br />11 PLAN CHECK FEE r 130,00 each SUBMIS5f011/RESUDMISSI011 ENVIRpf TT� tI At r ill 5 <br />.` REPAIR <br />P. rANK REPAIR FEE = 1110.00 each TANKI Tants x 1110.00 <br />A PIPING REPAIRICLOSUREIREMOVAL (fees are per hour, ainimua one hour to be paid on^plan submittal) <br />R UNAUTHORII,ED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING 111SPECIIO11 T' <br />(when applicable) (when apjl.icalrlel (when applicable) <br />FEE - 130.00Jhr�„� .- FEE --z 135-00/hr ��__. <br />FEE135,OOIhr1���: ; <br />---- �'"`-- r0 f Al. DUE T-3 <br />VFW tr3F oily <br />OEM ��1"� M ..""MOROMM �Lu l�IflICQb'��pl� ��11�If�l'i°�i�Q �7J��11�4C�!�1�+I�IC�IIU� 9�!l���II�f4��G�F��GP <br />SWEEPS I COMP I LOC CODE' DIST 60E AMOUIIf DUE MOUNT RrVD `�CHE'K;I/CASII '00 DY DATE P,ECEIV£0 PEP.MIT 1 <br />It <br />fJ ii yu i .— .� _._ . r._r._..-.- _ "' _ . .-•.._.. _- ....... .— ...... <br />)ter i �— ` - ..rr e�..r• <br />'�Ci���l�l� i ” P i�V �4 !±ulBPa�III R P� . +If VI!PP ISI �iJrP i i!l l�G,' �1;1�GUI�9l.li SIG 9��JJ9 QRIV IONI M NMI <br />p {{ I l 0 <br />�--- — — R9'?tll� qll. �II�IGA��I�I Ril�1?f�AfII�RI��iP�lti��llr�n�"TInII,M,.1f(.I@� <br />