Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> IhIfACILITY/SIiE NAME FACILITY CONTACT NAME <br /> C { I; 0WD Cd'` ti L C <br /> 1 <br /> L STREETADDRESS SITE PHONE 1 NITN AREA CODE <br /> 1 _ v I �� <br /> T-- <br /> Y CITY STAT ZIP CODEt of Tanks <br /> 5� 76� at Site <br /> A APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> P <br /> P S Gam_ <br /> L -- -- <br /> I MAILING ADDRESS APPLICANT PHONE 1 wl rN AREA CODE <br /> C <br /> A <br /> N CITY STAT ZIP CODE TYPE of APPLICATION <br /> I - _-- CLOSURE, INSTALLATION, ETC. <br /> fFACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A —JC 1986 1981 1988 1583 <br /> T _ — — <br /> I �D 1 a&; 1O l DC f �i�l <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks / x 150.00 1986 1987 1988 1989 <br /> A (Eultipiy I by fee for r 7 <br /> C each year applicable) S--6 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> T t Tanks_l__ x 156.00 198b 1987 1988 1989 �G <br /> Y (enter amount and year) — <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L o� <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks--)<-- 190.00 f <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 TANK t Tanks x 580.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L — - <br /> A <br /> U( PLAN CHECK FEE = $30.00 each SUBMISSION/RESUCMISSION f <br /> REPAIR <br /> F. TANK REPAIR FEE = $110.00 each TANK t Tanks------ x $110.00 f <br /> E — --- -- -- <br /> P -- — <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I -- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE = 135.00/hr FEE`$35.00/hr f <br /> TOTAL DUE is ` <br /> OFFICE USE ONLY <br /> ,WEEPS 1 .9.C1.I <br /> u <br /> s , y <br /> OMP t LOC CODE DIST CODE AMOUNT DUE MOUNT RPVD CHECK WASH REVD BY DATE RECEIVED PERMIT t <br /> t�cA. �Tl�Iij�`-I J. ?. <br /> >">�-�ro3i-ti�E SED Tzr�s �. <br />