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S0 JOAQUIN LOCAL HEALTH STRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> F �*ILITY/SITE NAME <br /> I¢ __ <br /> • � A. 1/511 gPauos; Jef <br /> L STREET ADDRESS BITE P}PONt WITH AREA eoom <br /> Y CITY STATE IIP CODE I# of Tanks <br /> at Site <br /> —� °� "--— -- —_ c4 <br /> _ -Q ---- <br /> A APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> P _ Mar/L <br /> f�r�c/�sonJ�/!�►,l�e /mss <br /> L <br /> --- -~- -•-- -_-- <br /> I MAILING ADDRE S APPLICA T PHONE t MIT" AREA C00! <br /> C Po. QaK 5d8 <br /> N CITY — — STAT ZiP'COOE TYPE of — <br /> .T (�••�Q, Cl0lURE INETALIATI ITC. .--_- <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> _ -- -- - -s - --- <br /> T 986— --1981 — —1988- E3 <br /> V <br /> E TANK FEE _ $50.00 each TANK _ <br /> 1 _ <br /> A u1tiPTy A by fee for 1986 �--1987 1988 _ y 1989^ f— <br /> C each year applicable) V <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) _ <br /> I <br /> -- <br /> T 1 Tanks x $56.00 1986 1987 1988 Ek6 <br /> Y (enter mount and year) Ca <br /> _ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) -- — — !— ——AY M E N T <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK <br /> U....__,_.— ----- —___ — — <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) _ _ <br /> E._ __ __—.._.--,_,_—______ k MENTAL HEALTff' <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK # Tanks — -x $80.00 PEE V1111JLRVI� <br /> P PLANCHECK (Installation or Repair) — —— —T— — — <br /> L <br /> H PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> P. TANK REPAIR FEE _ $110.00 each TANK # Tanks __!T z $110.00 -- <br /> E...._... — <br /> P ..-----__----....___..___---__ -- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) �— <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING 111SPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE F _ .00/hr FEE _ $35.00/hr <br /> EE $35 <br /> $ <br /> _.._ <br /> TOTAL DUE $ —� <br /> OFFICE USE ONLY <br /> �!I N mtlmmtlN � r �r° m � i � PJmmGNmNlmml!tlININ !INBtlIIII!;III!fiiflNillfi.119NmmNtltlCNlNI.1�NNN1CmNlml!II Vmtlmmimmtllmm4111mN�!P�1tlNlm) <br /> I !'!NI. „ NPdJNllmllm!mNl!NmmtllPkltlmNmltl11119tl,�mNm'�,Iltl, ImmIN�'mJlm�,iN�i81m9mICPcV'mmm�tlmmlN1..,',1m�immllG9tl,mll!!ImmNmtl7�RdNatl, <br /> SWEEPS # COMP # LOC CODE 01ST CODE AMOUNT DUE AMOUNT RCVO CHEr,K ASH RCVD BY DATE RECEIVED PERMIT f <br /> 1 15 _9... .. CO, _ ....... ..I.. tl I,Vtltllltl mtlNNNI,Vmmtltltltlll mlNmlmmlllllltltl1111 <br /> . I!�.Ip�n, I�Ntl �I �P��INm�I�N .�tlCNll.,ll tlnmlm!,mmmNtlmNNtlNmlmitl mml�mNNmm�N.u.�,I:mL ImImIN�m!Ntlmpmmtlm!Imi,tl NmINIPmlmmilm I!mltlmI mmltlll nn .!IlNlm��!mlmNlmmNN�amm!m��l <br /> 17 'tl0 �EV <br />