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f SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> F FACILITY/SITE NAME — - FACILITY CONTACT NAME <br /> A �+ <br /> I __—( OrAOf9/e SZE LPPhIC?1P L4± <br /> L STREET ADDRESS V SITE PHONE I utrm AREA Coef <br /> I _ <br /> -94/17 -9I22r7 <br /> Y CITY — STATE IIP CODE I of Tanks <br /> al Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P p <br /> P 54.�u-- <br /> L -- -- -- <br /> I MAILING ADDRESS APPLICANT PHONE 1 MIT" AREA Coef <br /> A _ _ <br /> N CI1Y STAT IIP'CODE APPLICATION <br /> CLOEURf IMRTALLATION. ITC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR, TOTAL <br /> A '— ---- -- - — -- --— <br /> T — 386 1981 1388 —1383 1 <br /> I <br /> V-- <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks 1 150.00 1986 1387 1988 1383 <br /> A I ullipiy 1-by lee for <br /> Ieach year applicable) — --��—" 1 <br /> LSTATE SURCHARGE T 156.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> I <br /> I 1 Tanks 1 156.00 1386 1381 1388 1303 <br /> Y (enter iiouit and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE - 130.00 each TANK 5 1 130.00 1 j Oa <br /> U ------— —— — --- — .— <br /> R TEMPORAn CLOSURE (Only alloyed one time for up to tvo years) <br /> E — -- -- <br /> TEMPORARY CLOSUP.E FEE 2 $80.00 each TANK II 1 Tanks — 1 180.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> M PLAN CHECK FEE = 130.00 each SUBMISSIONyRESUDMISSIUM $ <br /> REPAIR -- —P. TANK REPAIR FEE = 1110.00 each TANK <br /> Tanks------ 1 1110.00 f <br /> E --- —.----__.— -- ...___—_.._.-- --- ---.—....--- — --- —._ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IIISPECTION <br /> (vhen applicable) (vhen applicable) When applicable) <br /> FEE = 130.00/hr FEE = 135.00/hr FEE - 135 001h 1 <br /> TOTAL DUE 1 d <br /> OFFICE USC OMIY 11419%.i N1 11 — <br /> SWEEPS P 1,,,. LOC COOS II, i 1 ��, IM 17 1mmimm��i lR11 Ty i mm�mml�� �ll�m mmm�m <br /> DIST CODE AMOUNT DUE AMOUNT RCVD CHECK /CASH RCVD BY DATE P.ECEIVED PERMIT 1 <br /> s 3 cR7v 8' 1 . ... —_ _.. --- _ _. -- —/, <br /> 1�1 ;4� - <br /> a zs6z <br /> E,1 v i , mm� �mm�mn. nmmm mmiim�mr�i� . T�mni �mmnmmmTO mm�gh�mm�mm�mmmmnn) <br />