Laserfiche WebLink
1! <br /> • SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET -- <br /> IF FACILITY/SITE NAME -.----------_----------`— - <br /> FACILITY CONTACT NAME <br /> C <br /> I - SITE NONE `_WITH ARK coo[ <br /> STREET ADDRESS ��_ 1yy <br /> T -- 5T T IP CODE 1 of Tanks <br /> Y CITY S�7C;r' at Site <br /> A APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> P <br /> �(_-C <br /> L ---- - -�------ - -- = PPL CANT PHONE 1 W ITN AREA coo[ <br /> I MAI -tNG ADDRESS <br /> A -- _ - — <br /> T CITY STAT i �OD� TYPE el APPLICATION - <br /> -- --- <br /> FACILITY FEE 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 19AL 1988 1983 — ,--- — <br /> T 1 <br /> I — ---- <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks x (50.00 1986 1381 <br /> A (multipTy_1 by fee for ----— -- — — S <br /> C each year applicable) <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH I, SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x 156.00 1386 _ 1981 1988 1983 <br /> Y (enter iio6nt and year) ---- 1 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — _--_ <br /> L . _._—........._._.—___—.--- -- T 1 Tanks _ z $30.00 <br /> 0 CLOSURE FEE = 130.00 each TANK <br /> 5 --------- -- -- -- -- <br /> D, TEMPOP.ARY CLOSURE (Only alloved one time for up to two years) -----_- _— <br /> E ------......... <br /> -----— 1 <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK 1 Tanks x 180.00 -- <br /> P PLAN CHECK (Installation or Repair) <br /> A s <br /> HIPLAN CHECK FEE = $30.00 each SUBMISSION/RESU@MISSION <br /> REPAIR _ _ - <br /> P. TANK REPAIR FEE $110.00 each TANK 1 Tanks______ x $110.00 1 <br /> E- <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 IIISPECTION _ <br /> when applicable) (when applicable) (when applicable) <br /> FEE $30.00lhrl FEE 135.00/hr FEE = $35.00lhr <br /> I- tsTOTAL DUE <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK IICASH RCVD BY DATE P.ECEIVED PERMTT 1 — <br /> _ .r_.. _.— _ ----- ---- - - --- <br /> � .... � _ <br /> qg �n �, m GPRa4BI �, �V �1 <br /> E 1...13711 �V IT I"I -Yh'►s check <br /> a--, 0c' res a+ oma✓ SLr o iacI f i h�-S <br />