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1 <br /> BAN JOAQU I N LOCAL HEALTH D TR I CT <br /> i <br /> ,* NDERGROUND STORAGE TANK PROGRAM - FEE WORK& <br /> IF <br /> * F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> L STREET ADDRESS SITE PHONE I (with Area Code) <br /> T <br /> Y CITY STATE ZIP CODE Y of TANK'S <br /> at Site <br /> A APPLICANT/)BILLING NAHV APPLICANT CONTACT NAME <br /> P in <br /> P ( f ! <br /> L- <br /> I MAILIN ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C C7` <br /> A <br /> N CITY S AT ZI CODE TYPE of APPL[' <br /> T C (Closure, nstallatio , etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> I $ / <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks _ x $50.00 1986 1987 1988 1989 <br /> A (multiply # by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 4 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter amount and year) 0 $ /1 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks x f9U.04 $ <br /> S ----- <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 $ Tanks x $80.00 <br /> x P PLAN C K (Installation <br /> L Repair) <br /> - <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> p $ Tanks x f114.00 $ <br /> - --- <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I LOC CODE DIST CODE <br /> AMOUNT DUE f AMOUNT <br /> d RC°VFDf.^M CHECK <br /> HECKl $/r C1AS.('.H:.. RA.Cr'VD BY Y' . DATE <br /> ATE RECEIVED <br /> -� PERMIT M <br /> 1 , if <br /> viz <br />