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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PR06RAN - FEE WORKSHEET <br /> 1A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C <br /> 1 " „ <br /> L STREET ADDRESS SITE PNONE ! WITH AREAoos <br /> r <br /> ° c <br /> - 3 - .Z.? q <br /> Y CITY STAT TIP CODE t of Tanks <br /> at Site / <br /> APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE ! WITH AReA coot <br /> A 20 - 5-- ,2600 <br /> T CITY STAT ZIP'CODE TYPE of APPLICATION <br /> CLOeURC, INCTALLATION. CTC. <br /> [STATE <br /> ITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> 1986 1987 1988 1989 <br /> f _ <br /> EE _$50.00 each TANK Ty EC E I`J E D <br /> s x t50.00 i986 1987 1988 1989 <br /> ipTy!-by fee for <br /> year applicable) <br /> L <br /> SURCHARGE = f56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applidl( lMEVTAL HEALTH <br /> s x 556.00 1986 1987 1988 1989 �ITISE VICE iiouot and year) <br /> t <br /> ETEMPORAPYCLOSUP'EOF(EE <br /> SURE (Removal or Closure-in-place) <br /> $90.00 each TANK t Tanks_)_ x $90.00 f <br /> SURE (Only allowed one time for up to two years) <br /> TEMPO <br /> URE FEE _ $80.00 each TANK ! Tanks x (80.00 f <br /> ELAA AN CHECK (Installation or Repair) <br /> N CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> ITS <br /> REPAIR -- <br /> R TANK REPAIR FEE _ $110.00 each TANK <br /> E t Tanks x f110.00 <br /> P f <br /> ---- - — <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 /> (vhen applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr FEE = $35.00/hr FEE = 135.00/hr s <br /> TOTAL DUE s <br /> OFFICE USE ONLY <br /> .i'a. T. .. I 9"Imm" <br /> ..' t. =PECEMIT <br /> ZNEE COMP t LOC CODE DIST CODE AMOUtiT DUE AMOUNT RCV CHE /CASH RCVD DY DAt <br /> b7FNrv�C �� 2 — 90 1,,5-2 el 7 iff <br />