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SAN JOAQUIN LOCAL. I-IEALT14 DISTRICT /t/ <br /> I ,. UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> F FACILIIYlSIfE NANE FACILITY CONTACT NAME <br /> A ,I ' <br /> LI <br /> STREET ADDRESS SITE PHONE 1 "ITN aRta comm <br /> T --1—t2O /�/, / _ _ <br /> Y CITY STATE UP CODE 1 0l tanks <br /> �at Site V <br /> A APPLICANTI LIRG NAME <br /> P I APPLICANT CONTACT NAME <br /> L ._ O/ ' <br /> I MAILING ADDRESS APPLICANT PHONE 1 <br /> MIT" AREA COO[ <br /> N CITY IIP'CODETYPE of APPLICATION <br /> T 'LOOURe. INOTALLATIO", ETC. <br /> A <br /> FACILITY fEE = 1100.00 each SITE ADDRESS per YEAR. <br /> C _ _ TOTAL <br /> 1986 1987 —-13AB — —1383 <br /> I Q Z� <br /> I <br /> -- 06- 1 /OD- L/ oto J /coo— loD- 1 SO <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks x 150.00 1986 1387 1988 1983 <br /> A (mulHpTy t"by lee for <br /> C each year applicable) '-- <br /> L STATE SURCHARGE = t5G.00 each TANK (see CA HEALTH I SAFETY CODE Sec 15287 for applicability) <br /> I — -- _ <br /> T 1 Tanks x 1511386 1987 1988 1383 <br /> Y (enter mount and year) -- --- �T _ - - <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> S CLOSURE FEE _ 190.00 each TANK 1 tanks x 130.00 1 <br /> U._.—. ——.— — <br /> P TEMPOPARY•CLOSUPE (Only allowed one time for up to two years) <br /> E — —_ -- <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks x 190.00 f <br /> PPLAN CHECK (Installation or Repair) I — <br /> A -- ----- --- - - -- — <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUDNISSIO)I 1 <br /> REPAIR -- — — — --- -- <br /> P TANK REPAIR FEE = 1)10.00 each TANK <br /> E- 1 Tanks s (110.00 1 <br /> A PIPING PEPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IIISPECTION <br /> When applicable) ("hen applicable) (when applicable) <br /> fEE = 130.00/hr — - <br /> FEE _ $35.00/hr� FEE = 135.------------ <br /> 00/hrr $ <br /> TOTAL DUE f� <br /> OFIfCC USC OAZY <br /> WEEP$ 1 CO 1 �DC CODEDIST <br /> 61�B1 l�Im'�I III II�!�II�I11�IA�I "�ll�fl�ll IfRI .VII I^,Ito I t1�41�1II�IIfiMIIIIIflIB II r�G�I�PI j <br /> I � DIS <br /> T CODE ANOUIIT DUE AMOUNT RC"D CHECK WASH RCVD BY DATE P,ECEfVED PEPMIT 1 <br /> E� ji : v I / mmnnnmmm�fl��nm n �mmnmm�i, mr�msfinnm mOiI II� � I i mm�mnn mmnn�nm mm h�n��mnln ornnnr <br />