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5HN JOAQUIN LOCAL HEALTH DI ICT_ <br />ARGROUND STORAGE TANK PROGRAM - FEE WORKSHE <br />F FACILITY/SITE NAME <br />FACILITY CONTACT NAME <br />. <br />� <br />,CI <br />I r'o S <br />1986 <br />L STREET ADDRESS <br />SITE PHONE #-MIT" AREA CODE <br />1989 <br />R <br />E <br />T <br />Y CITY <br />ISTAT <br />IIP CODE <br />i of Tanks <br />Site 4 <br />$ <br />I <br />at <br />A APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />1986 <br />P <br />1988 <br />L <br />A PIPING REPAIR/CLOSURE/REMOVAL <br />I MAILING ADDRESS <br />APPLICANT PHONE t MIT" AREA CODE <br />C <br />A <br />I <br />T CITY <br />STAT <br />IIP CODE APPLICATION <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br />CLOSURE, INSTALLATION, ETC. <br />A- <br />FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br />_ - — <br />TOTAL <br />,CI <br />CLOSURE FEE = $90.00 each TANK <br />1986 <br />1987 <br />1988 <br />1989 <br />R <br />E <br />TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />$ <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />I Tanks x $80.00 <br />$ <br />$ <br />I <br />E <br />TANK FEE _ $50.00 each TANK <br />F <br />A <br />I Tanks x $50.00 <br />(multiply -i -by fee for <br />1986 <br />1987 <br />1988 <br />1989-^ <br />A PIPING REPAIR/CLOSURE/REMOVAL <br />(Fees are <br />per hour, minimum one hour <br />to be paid on plan submittal) <br />�--- <br />I <br />C <br />I <br />each year applicable) <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br />T <br />Y <br />I Tanks__,_ x $56.00 <br />(enter amount and year) <br />1986 <br />1987 <br />1988 <br />1989 <br />(when applicable) <br />(when <br />applicable) <br />(when applicable) <br />FEE = $30.00/hr <br />C <br />L <br />PERMANENT CLOSURE (Removal or Closure -in-place) <br />0 <br />S------ <br />CLOSURE FEE = $90.00 each TANK <br />I Tanks x $90.00 <br />$ <br />U <br />TANK <br />R <br />E <br />TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />$ <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />I Tanks x $80.00 <br />$ <br />L <br />PLAN CHECK (Installation or Repair) <br />�- <br />A <br />N <br />PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br />$ <br />REPAIR <br />R TANK REPAIR FEE = $110.00 each <br />TANK <br />I Tanks x $110.00 <br />$ <br />E <br />P <br />A PIPING REPAIR/CLOSURE/REMOVAL <br />(Fees are <br />per hour, minimum one hour <br />to be paid on plan submittal) <br />I <br />R UNAUTHORIZED RELEASE EVALUATION <br />CONSTRUCTION INSPECTION <br />SAMPLING INSPECTION <br />(when applicable) <br />(when <br />applicable) <br />(when applicable) <br />FEE = $30.00/hr <br />FEE = <br />$35.00/hr <br />FEE = $35.00/hr <br />$� <br />__....�. TOTAL DUE <br />$ <br />OFFICE USE ONLY <br />OEM <br />SWEEPS I COMP D LOC CODE <br />DIST CODE <br />AMOUNT DUE AMOUNT RCVD <br />CHECK 1/GASH RCVD BY DATE <br />now= <br />RECEIVED PERMIT I <br />CHH iI i <br />0t�� <br />