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• SAN JOAUUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE VORKSHEET _--- <br /> r1fACr IACKUYISIT!, <br /> KUYISITE MANE FACILITY CONTACT NAME <br /> 1SITE PHONE 1 tr*w A"tA 0006 <br /> L STREET AIDRESS _ r <br /> 1 3 CASA( IF — <br /> T STAT CODE 1 of Tanks _ <br /> Y CITT at Site I U <br /> A APPLICANTIOILIiNA NAME APPLICANT CONTACT NAME <br /> P hrd (GS <br /> APPLICANT PRONE 1 wtrw AetA mese <br /> nA C� ADO¢E3DC'_ 5 � <br /> A ,(E�� — — Si i 11P'COOE TYPE of APPLICATION <br /> N g1T�, ___----� in <br /> etuet. rwA«ATrew. ere. - filO�Tii <br /> TOTAL <br /> FACILITY rEE = 1100.00 each SITE ADDRESS per YEAR <br /> — <br /> T <br /> E TANK FEE _ 150.00 each TANK E— <br /> I 1387. 138A (wltipry1-by fee for <br /> C each year appli4able) — ----� _-- __ —_ E <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 1 MIT CODE Sec 25287 for +pPli(ability) <br /> 1 1 Tanks r 156.00 -- 1386 1381 1388 1383 <br /> Y (enter iiiiit and yen) 1 <br /> P• PERMANENT CLOSURE (Removal or Closure-in-plate)�— <br /> 0 CLOSURE FEE _ 130.00 each TANK i 1 ianks___� s 130.00 <br /> S ----.------- — <br /> P TEMPORARY CLOSURE (Only alloyed one tine for up to too years) <br /> TEHPORAPY CLOSURE FEE = 180.00 each TANK 1 tanks ----- s 190.00 ---_ <br /> P PLAN CHECK (Installation or Repair( _.—_----- ---- ----- <br /> L - -- --- <br /> H PLAN CHECK FEE = 130.00 each SUBMISSION/kESUeMISSIOM —�-- 1 -- <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> P <br /> A PIPING REPAIRICLOSIg1EIREMfNAL (fees ue per hour, minimum one holt to be p+t0 an Plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATIONCONSTRUCTION INSPECTION SAMPLiNG IIISPECTION <br /> When applicable) Ivhen appltuble) /vhen applicable) <br /> FEE = 130.00/hrFEE_._{35.09/hrI- — — FEE _ {75.00/hr� <br /> TOTAL DOE 1 <br /> OFFICE ISE ON(r <br /> - <br /> ;NEEDS 1 COMP 1 LOC COOE DIST CODE hn0U111 DUE AMOUNT RCVD CHECr IICASIT H &CVO RY DATE RECEIVED PERMIT 1 <br /> GoGUR i3 3Z <br /> i F?f. t V f <br />