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SAN j OAQU I N LOCAL HEALTH D i— I'R I CT <br /> ' UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> - - --- -- -- ----- --- -- <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> I -- <br /> L STREET ADDRESS SITE PHONE # WITH AREA CODE <br /> T-- <br /> Y CITY STATE ZiP CODE # of Tanks <br /> 5 Q� — — at Site — <br /> A APPLICANT/BILLING NAME c \ APPLICANT CONTACT NAME <br /> P <br /> F' —J \C x �'Z0,c f_ J tt �eln <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> N CITY STATE ZIP CODETYPE of APPLICATION <br /> T C108URE. INBTAIIATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR, TOTAL <br /> C 1966 1 98 7 1988 1989 <br /> T —— <br /> I f <br /> E TANK FEE _ $50,00 each TANK <br /> F I Tanks _ x $50.00 1986 1987 1988 1989 <br /> A (multiply_E by fee for — - — <br /> C each year applicable) f <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x (56.00 1986 1987 1928 1989 <br /> Y (enter mount and year) - ----- --- — <br /> i' PERMANENT CLOSURE (Removal or Closure-in-place) <br /> D CLOSURE FEE = $90.00 each TANK I Tanks------ x $90.00 S (� <br /> S ---— — ---. -- <br /> IR TEMPOP.AP.Y CLOSURE (Onlyallowedone time for up to two years) — — <br /> E-- <br /> TEMPOP,ARY CLOSURE FEE = $80.00 each TANK T# Tanksx 180.00 f <br /> IP PIAN CHECK (Installation or Repair) ,.., , . -77 <br /> IN PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION `f <br /> � �ENTAL Hr. <br /> R TANK REPAIR FEE _ $110.00 each TANK # Tanks )PEl`P0,'p , %SERViCE- f <br /> -- --- <br /> F' <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 /> ---......_.__................ <br /> FEE = $30.00/hr( FEE = 135.00/hr _ FEE _ $35.00/hr f <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> �TmWEEPS # !! "C;OM����IL�OC'CODEDIST r,ODEI�AMOU���D E''''AI�MnAOUiIN�T��mP,rlp ITCH , ml ! !;!tl����l���* <br /> n n nn m !IIW' 41flG°WI !� <br /> ECK /CASH RCVD Y DATE RECEIVED PERMIT # <br /> __._.. .._....._..._........_....._.. ._.... ._... .__ ..._. ......_/LL.'^...C <br /> !hl II nt n nn 1 .... )�� Iry I I n IAP` I�I I ' PI n N I tI�AA I n nl cI m• I -- <br /> nn:,ll�,uq!l�m!r� .r.""mrrip�Igl�imT .'Gilrt9t !'!� i! �f�!TI:;,I:!!(�� !I!.��I! i liT.! G�� !;11r�i��i( nl�nl�r!iulVulu Ikti!a�f�u u GI�I!'f . ��f '! u:�u�iCi!I�i l9�!GI�'S�)�11!!,u"1711�Itd,�i, <br /> to Zs 0-41— rSt>; ,78 . SII ���Gfi�l ! I a <br />