Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UN 20UND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME _ FACILITY CONTACT NAME <br /> A <br /> s CSf .J <br /> IT Si Rau E , 1_ <br /> i L STREET ADDRESS SITE PHONE 1 WITH AREA c00 <br /> �-oql - 9(-1 q _ss6 6 <br /> i <br /> Y CITY STAJE IIP C0 t of Tanks <br /> 5 can H at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P Sz4-V1r m L ores <br /> , MAIL G ADDRESS APPLICANT PHONE 1 WITH ARRA CODE <br /> A <br /> o SGS �o�i - 4�L4 -8333 <br /> N CITE, STATEI ZIP CODE ITYPE of APPLICATION <br /> CLOAWI[. INSTALLATION. ETC. <br /> FACILITY FEE =`1100.00 each SITE ADDRESS per YEAR `lam J O CJ 1 TOTAL <br /> A — - - <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 S <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks _ _ s 150.00 1986 1387 1988 1989 <br /> A (multipTy ( by fee for <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 4 SAFETY CODE Sec 25287 for applicability) y <br /> 1 I Tanks 1 $56.00 1986 1 1987 1988 1 1983 <br /> T (enter aiount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) FST <br /> L <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanksa $90.00 % Sc 1 <br /> S -- T _---- <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__ 1 $80.00 is <br /> P PLAN CHECK (Instillation or Repair) <br /> L <br /> A <br /> If PLAN CHECK FEE 130.00 each SUBMISSION/RESUBMISSION 1 <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK t Tanks s 1110.00 $ <br /> E - <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I -- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.00/hr FEE = 535.00/hr D FEE _ $35.00/hr w 1 a <br /> TOTAL DUE $ � <br /> OFFICE USE OILY <br /> S <br /> v <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br />