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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />.... ...... <br />FACILITY/SITE NAME <br />FACILITY CONTACT NAME <br />1A <br />C &ev[Zo`ia GetzviLT✓ S- p,-no+_A- <br />I <br />T 1 Tanks x $56.00 <br />Y (enter aeount and year) <br />I <br />L STREET ADDRESSSITE <br />T <br />PHONE If WITH AREA CODE - <br />CZ-OcO4-1-1 -uy4-1 <br />Y CITY <br />STAT <br />.YIP CODE <br />t of Tanks <br />S%u'C-1:'T'o <br />Z�A <br />9S ?f�>S <br />at -Site <br />_ <br />A APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P IRv�e-i l_.T✓a �i5 i �.'f �s <br />4r��c—H <br />L <br />- <br />I MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />A i?�3—I �y icf ��/� ZI I <br />Lyle lv`t(rr-C�3 <br />TCITY <br />STATE <br />Z.IP'CODE <br />TYPE of APPLICATION Riap^lP_ <br />�M1: "10 <br />C� <br />U <br />%-Se,2 <br />CLOSURE, INSTALLATION, ETC. <br />FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br />A -- <br />C — 1986 1981 1988 1989 <br />T - - <br />I S <br />E TANK FEE = $50.00 TANK <br />each <br />F I Tanks _ x $50.00 _ 1986 y 1981 1988 _ -1989 <br />A (:ultipTy_Fby fee for <br />C each year applicable) <br />L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25281 for applicability) <br />I <br />T 1 Tanks x $56.00 <br />Y (enter aeount and year) <br />1986, <br />1981 <br />-- <br />1988 <br />- - <br />1989 <br />- <br />- --- <br />- <br />$ <br />C PERMANENT CLOSURE (Removal or -Closure -in-place) <br />- - <br />L_-- <br />0 CLOSURE FEE = $50.00 each TANK <br />Tanksx $90.00 S <br />S _ <br />—�I _ <br />U <br />R TEMPORARY <br />- <br />to two <br />CLOSURE (Only allowed one time for up <br />years) <br />E-•---- -- --- --- ----- -- -_— - _--- <br />TEMPOPAP,Y CLOSURE FEE _ $80.000 each TANK _- <br />_ -- - --------- -----_ _ -- — <br />I Tanks --- -- x $80.00 _ ---- f <br />........ -•---•---•--•--_-- <br />IP PLAN CHECK (Installation or Repair) <br />AIN <br />PLAN CHECK. FEE = $30.00 each SUBMISSION/RESUBMISSION <br />(REPAIR <br />P.TANK REPAIR FEE = $110.00 each TANK 1 I Tanks _ x $110.00 $ <br />IE <br />IP ._._.............. -- ............- <br />IA PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, ainimum one hour ::, be paid on plan submittal)-- -- -- _ <br />1 .. .......... ..... __..._.._.._.__....._._...- ._....-._.._...- _ ..._.. _...... ................. <br />_- -- - - <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION IN'S'PECTION SAMPLING INSPECTION <br />(when applicable) (when app`licabl(i ;vhen applicable) <br />_-- — <br />-- - SSSS....... <br />SSSS.... <br />.. -- - ___ _.. � -•-• -•- -._ SSSS <br />FEE = $30. 0/hr FEE - $35.00/hr FEE _ $35.00/hr S <br />TOTAL DUE <br />OFFICE USE ONLY <br />SWEEPS I I COMP I LOC CODE DIS AMOUNT DUE AMOUNT RCVD CHECK, I/CA VD DY DATE P,ECEIVED PERMIT I <br />_. �. .............. <br />_ Z3. .......-'z_-_— <br />