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JOAQUIN LOCAL HEALTI .'STRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A �/ y <br /> C <br /> I <br /> I STREET ADDRESS Q SITE PHONE Y (with Area Code) <br /> Tvrvcr��i✓� <br /> Y CITY STATE ZIP CODE Y of TANK'S <br /> Is "aA� 3ii at Site <br /> IP APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> A <br /> N CITY STATE lIP CODE TYPE of APPLICATION <br /> Z c /C 411 (Closure, Installation, etc.) <br /> PA <br /> f- SIO0.00 each SITE ADDRESS per YEAR <br /> TOTAL <br /> 1986 1987 1988 1989 <br /> $50.00 each TANKx $50.00 1986 1981 1988 1939 <br /> A Multiply( by fee for <br /> L SATE SURCHARGE --- — -- -'- <br /> I $56.00 each TANK. (see CA HEALTH S SAFETY CODE Sec .5287 for applicability) <br /> T 1 Tanks 1 $56.00 1386 1987 I'i88 1939 <br /> Y (enter iiount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) - <br /> L <br /> 0 CLOSURE FEE = $30.00 each TANK <br /> S $ Tanks x (90.00 y <br /> U _ <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPBP,ARY CLOSURE fEE = 580.00 each TANK 1 Tanks x 580.00 <br /> P <br /> L PLAN CHECK (Installation or Repair) <br /> A _I <br /> N PLANI CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> $ J <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE = 5110.00 each TANK 1 Tanks x $I10.0o $ <br /> P <br /> IA - <br /> [ PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to he paid submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION NO <br /> (when app!i able) INSPECTION INSPECTION <br /> FEE = A30.00/hr FEE = $35.00/hr FEE _ (35,00/hr y `�S C/L <br /> OFFICE USE ONLY L DUE <br /> SWEEPS f !COMP ' LOC CODE DIST CODE AMOUNT DUE AMOUNT RC VO CHECK 1/CASH RCVO BY DATE 1E1EI1E1 LPE111TI <br /> .gym / 3 3 <br /> OM a A, <br /> Ln ZJ <br />