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SAN JUAQUIN LOCAL HEALTH DIS-AICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> A FACILITY/SITE NAME - -� FACILITY CONTACT NAME <br /> � G'if�EfJ�il��1S'/9 �i917 fFl,9Hi`� <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA CODE <br /> Y CITY STAT 11P CODE 1 of Tanks <br /> PAPPLICANT/BILNAMELING ����✓ — APPLICANT CONTACT NAME <br /> 1 MAILING ADDRESS ,,/� APPLICANT PHONE 1 WITH AREA Coos <br /> A /�O.QCJ1C `�i7d� — _ 4991-.7Xi421 <br /> N CITY /�A,(moi STA 1[ CODE PPLICATION <br /> � rJv LREYRE I"TALLATION, ETC. <br /> FEE = 1100.00 each SITE ADDRESS per YEAR - TO <br /> A -•--_..C <br /> -_ -•--_.. <br /> f -- 1986 - 1987 1988 1989 1 �- <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks z '50.00 1986 1387L <br /> 1988 1989 <br /> A ( ultipfy 11by fee for ---each yearapplicable) - J 1 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH i SAFETY CODE Sec 25287 for applic <br /> T 1 Tanks s $56.00 --- -^1986 - 1981 1988 - <br /> - ►383 <br /> Y (enter aiouiit and year) - — <br /> — 1 <br /> C PERMANENT CLOSURE (Removal r Closure-in-place) ,�? ,qav /C�J --,-402V <br /> O.'L <br /> 3 CLOSURE FEE = 190.00 each TANK t Tanks_ _ x $90.00 ! 7 <br /> U — <br /> P PLAN CHECK (Installation or Repair) ----__ -- <br /> A - <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION f <br /> REPAI <br /> R TANK REPAIR FEE = 1110,00 eacM"fYiNIG 1 Tanks x $110 f <br /> -- ---- -- _.-. -. . <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be. aid on plan submittal) <br /> I ------------ - _ ._...-- - -- ---, _ -._...-...--- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING I)IS <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = f30 00/hr FEE $35.00/hr FEE _ $35.00/hr $ <br /> -.._.._.. ...... ... <br /> TOTAL DUE f Q <br /> OFFICE USE ONLY <br /> WcUSN1Rd 31,119111$9� <br /> 'SWEEPS / COMP 1 I LOC CODE DIST CODEIf AMOUNT DUE . AMOUNT( RCVO (CHECK t/CASH RCVD BY DATE RECEIVED �ER1111 <br /> @ 969V@A190a�V�P.�I�I ! 19999x1 �I� WI , i . JIV91J99fi.�lll�69 ILd�1911 ;GJ�V91VVI91aliuillVll fufiliiili 91GIII� <br /> e'---'- <br /> 'T'aa�!h� �dVJVC1VIIL_ ,��Nml.ll!18�IIIIII!III�IIIIIIiN:�lll�i!11�91i�f�llln!n@nl��1i110�41 III!%I�Idn@9V.VIIII�IIiI!�._ .J�.� !flV.ulll�l9iV.1191! . IIIIIIIVI�11iIV1211� (!!9111 illlll!�f9ii11�IRIiVIIIlT,9111VG9�!I <br />