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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM --FEE WORKSHEET <br /> TACILITY/SITE NAME FACILITY CONTACT NAME — <br /> C 1� <br /> I --- <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> 1 7-32Co Ozoc) 943-13i l <br /> T ---------- - -- <br /> Y CITY (( �STATE�TIP CODE I of Tanks <br /> S jDC 10-'--- _ _ _ __ '�� 95zo j at Sits CX«-�r its <br /> A APPLICANT/BILLING NAME I —y - APPLICANT CONTACT NAME - <br /> P �t E�j {-}. �G /�55�G1 A i!:5 RICK V)C-C&L1l,-��' <br /> L ----•--•--.__.__ ____— _-___ _—.-.___.._______— -___ -- <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> A �11owc AyE� Sud.,=_21i�� __ -- L9i�� (64(6-4003 <br /> f_I-Y____� ^__ _--._`_,_ _ -- - STATE n t IP'CODE TYPE RE APPL IC ~ <br /> � -1�/-'�I� �'V I U-- - �S CLOSURE,VREr d'i•Or ETC.IN�A �/� <br /> oo <br /> FACILITY FEE = $100.00 each SITE ADDRESS per `IEAR� �� TOTAL <br /> p � ----------- <br /> 1986 <br /> _-_-_-__ <br /> C _ 1986 1987 1988 1989 M19 g O <br /> T - <br /> i i 00_ o 0 <br /> E TANK FEE _ .$50.00 each TANK <br /> F I Tanks 3 x $50,00 1986-•-- __. 1987 -.-_1988 �- ._.._.-198'3 �90 ___-- <br /> A (mu l t i p ry_Fby fee for <br /> C each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH h SAFETY CODE*Sec 25281 for applicability) t <br /> I -__— - --- ---- -----__ - _-- - - --- <br /> T I Tanks 3 x $56.00 _ 1986 - 1987 1988 1989 199b --- <br /> Y (enter mount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) - ���-- T - u <br /> 0 CLOSURE FEE = $90.00 each TANK I Tanks__ x $?0.00 $ �? <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 TANKI Tanks _-x $80.00 <br /> P FLAN CHECK (Installation or Repair) - <br /> 1 <br /> X11 FLAN CHECK FEE._ $30.40 each SUBMISSION/RESUBMISSION 3b.o© <br /> REPAIR <br /> F. TANK-REPAIR FEE _ $110.00 each TANK 11 Tanks _ ___ x$110.00 $ Qj <br /> E _._ ___._._�_..._______ ____- -- _._._____. -____ ----__....._----._ __�__-..__.______._.___-.__._-__ ____ —_-- <br /> FM_— <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum onehour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION C'"nRUCTION INSPECTION SAMPLING INSPECTION <br /> when applicable) s+heapplicable) (when applicable)- ---.__ .-..—___ <br /> FEE _ $30.00/hr FEE _ $35.00/hrr FEE _ $35.00/hr $ <br /> TOTAL DUE #- <br /> OFFICE USE ONLY Li <br /> Rq 1... .. q . , q lq�gq�1 x d glg11011aP�iq ggqqq iillgfgq� q ' <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT 'RCVD CIRK CASH RCVD BY DATE RECEIVED PERMIT I <br /> • 'ru�"�,7 .�.,II1'�q I� 4,, .�ilggg9q+ nq.�ll ,L ��ggq�q�lq�lgq!�Cdl. .qqq ' '�ggllgq{illqil i <br /> •� ��r4� � �il!q'�fggqqqqli�IN>Rq �. ,. q�q ggiqlq[q�lql�liqqqqql,.lq �ggqlqq�� <br />