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8 JOAQUIN LOCAL HEALTH STRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> Y F FACILITY/SITE NAME <br /> A p / FACILITY CONTACT NAME <br /> g <br /> STREET ADDRESS SIT PHONE $ twith Area Code) <br />*� T <br /> Y CITY STATE ZIP CODE t of <br /> at trK u,au <br /> A APPLICANUBILLING WV APPLICANT C ACT <br /> 041989 <br /> [ MAILING ADDRESS <br /> CIZ APPLICANT PHA ' ,` � � � ` <br /> A . Q, / <br /> N CITY S AT II �3 TYPE of APPLI <br /> T 7 /9- G 4j iClosure, nstallatio , etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks g9t, z $50.00 1986 1987 1988 1989 <br /> A (multipTy 1-by fee for <br /> C each year applicable) <br /> I <br /> L <br /> STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> T N Tanks ., x $56.00 1986 1987 1988 1989 <br /> Y (enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) '— <br /> L <br /> 8 <br /> CLOSURE FEE _ $90.00 each TANK 1 tanks__ __ x $90.00 $ <br /> U <br /> E TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks x $80.00 <br /> L PLAN C K (Installation Repair) <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> 36 <br /> R REPAIR <br /> E TANK REPAIR FEE _ $110.00 each TANK t Tanks - <br /> x s110.00 $ <br /> A <br /> R PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTIONSAMPLING <br /> (when applicable) INSPECTION SNSPEG110N <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE <br /> TOTAL DUE $31 <br /> OFFICE W ONLY - <br /> � : <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 0/CASH RCVD BY DATE RECEIVED PERMIT { <br /> 60 vat 147vu <br /> .• . ;� . :v�ckn:oeaNA•�aaHtissa;gn 4;Rf d�StvNM .w;r r z e,�y : �+�.u..�y�:,s!w•,:igo <br />