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SAMaOAQUIN LOCAL HEAL.TNTR I CT C� <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME _ <br /> A <br /> C San Joaquin County Hospital Maintenance Yard Lee Ehrhardt <br /> I <br /> L STREET ADDRESS SITE PHONE i (with Area Code) <br /> I 500 W. Hospital Road 209 468-6994 <br /> T <br /> Y CITY STATE IIP CODE I of TANK'S <br /> French Camp CA lit Site 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C <br /> HA <br /> N CITY STATE IIP CODE TYPE of APPLICATION Tank Removal <br /> T (Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T <br /> I $ <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks x $50.00 1986 1981 1988 19813 <br /> A (multiply--1-by fee for <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks x 156.00 1986 1987 1988 1989 <br /> Y (enter iiount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> O CLOSURE FEE = $90.00 each TANK t Tanks__-1 x $90.00 f 90.00 <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 t Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R <br /> ETANK REPAIR FEE = 1110.00 each TANK D Tanks x $110.00 f <br /> P ----- <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 <br /> TOTAL DUE f (� <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I) LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT / <br /> a <br />