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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGRO STORAGE TANK PROGRAM - FEE VORKSHEET <br /> IF <br /> FACILITYISITE NAME FACILITY CONTACT NAME <br /> 6-Z e e,er <br /> L STREET ADDRESS SIi PHON I With Area Code) <br /> 1 q52 s. WILA-PN u1A`Y -582� <br /> Y CITY�„� 1 ' STATE ZIP CODE I of TANK'S <br /> !!rrp(4-r0!!VV GA1 X52.01 at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P W Q01 f2 CoN��rt0f(c `� l G JOP0 <br /> I MAILING ADDRESS APPLICANT PHONE f With Area Code) <br /> C P.O. PX�X 1210 26L7) CO3a-fq€�O <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T ILILAfZF ICA. c��275 (Closure, Installation, etI:. FgFrrlafJeNT <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A i <br /> C 1586 1581 1988 (y8•l <br /> T <br /> I � <br /> V <br /> E TANK FEE = 00.00 each TANK <br /> F I Tanis 1150-00 <br /> 1586 1981 1.333 1'33'3 <br /> A (rultiprp T-by fee for <br /> each year applicable) $ J` <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH i SAFETY CODE Set 252d1 for appik ability) <br /> I <br /> T I Tanis x 1%.00 1386 1981 h388 1133 <br /> Y (enter Uaunt and year) <br /> C PERMANENT CLOSURE (Rerova r Closure-in-place) <br /> L PIWO VQ L <br /> O CLOSURE FEE = $90.00 each TANK I Tants- _ x $50.00 <br /> S <br /> u <br /> R TEMPORARY CLOSURE (Only alloyed one tine for up to hyo years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $30.00 each TANK I Tants/ x $30.00 { <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSIONIRESUBMISSION $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE = $110.00 each TANK I Tants x $110.011 t <br /> P <br /> A - <br /> I PIPING REPAIRICLOSURE/REMOVAL (fees are per hour, aini+u,s one hour to be paid on plan subrittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING -` <br /> When applicable) INSPECTION INSPECTION <br /> FEE _ $30.00Ihr FEE _ $35.00/hr FEE = 525.001hr $ <br /> TOTAL DUE $ 7�• <br /> _OFFICE.IlSE OYir <br /> { '{trNNt•ig 1�1' fin.+uM •�w 0.ti:.�a <br /> SVEEPS I COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT I $ <br /> ZFp.aY, —•Y.•• 1+ .I+w� i•a.. .NI `.-n a. .i..ln� wl •Fw .'•++.a, yt••:..i�wyr .. � <br /> • <br /> •',�•�°'��� �'°� •�.�;a... �yes f rtti���.r!�!c 7v �+7,v re!nc�.!x�Mran`;�{r'''�-.^•,rr-,��.............,�-•e�.r+•-,.�",s nr-w„ts�4++.�,{e+, <br /> J' N3�-i'm'p .. .- - - _ 1.. _.. . ... .� v�e',i.y F i. ri•_ •e'.i:..r_.•.nV/ P.Y.•Sh.. 1':, <br />