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SAN JOUIN LOCAL HEALTH DIST*CT <br /> UND - DUMB STORAGE TANK PROGRAM - FEE <br /> Y - E <br /> FACILITY CONTACT NAME <br /> IF1FACILITY/SITE NAME 1 ASO wA r <br /> 9. sNEU- SE�vIG 7 5T�t loN 1'l �{ IaEL C� - <br /> I -- '-'--' --'- — SITE PHONE t WITH AREA CODE <br /> I STREET ADDRESS q �� kE-1 i�(�A�I �. �7y�� 33d '4 SZ3 <br /> T ------ STATE 1[P OBE t of Tanks <br /> Y CITY -C )r? Cfa- CPA at Site --__—_ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P �2oF3EQT N ��. AsSc�. J E FF T-*YLo� <br /> P — ------ <br /> L_—_____...___—_--- ----------- APPLIC T H $ WITH AREA CODE <br /> I MAILING ADDRESS 1337 F A!EZI 1 (qty �� 4-c03 <br /> AI' -- - - — - STATE TIP CODE TYPE of APPLICATION CL0%.1 ME <br /> Jf,ITY �- —---- ---=_-- — — c�aeuRE. IHETAuenDH. ere. �S I/VI IATI <br /> T F-1--i To _cA °lS�ZS _ -�•--- <br /> -- - - TOTAL <br /> FACILITY FEE _ $100,00 each SITE ADDRESS per YEAR -- -_ _-_- -- <br /> A 1986 1987 1988 1989 <br /> C --- - <br /> — - -- <br /> N/d ' _— <br /> E TANK FEE _ $50.00 each TANK <br /> - _-•_-- __ —_- —.--- -- <br /> F 1 Tanks x t50,U0 - - -1986^ 1987 <br /> A (multipfy 1 by fee for <br /> C each ear applicable) <br /> .CHARGE _ $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> s $56,00 1986 1987 1988 <br /> T CLOSURE (Removal or Closure-in-place) - <br /> FE - -- ___- t Tanks--3— x $90.00 S 'L ('• o0 <br /> Y CLOSURE (Only allowed one time for up to two years) <br /> RY CLOSURE ET- S80.00 each TANK A' Tanks_--_-- x — <br /> P PLAN CHECK (Installation or Repair) _- <br /> A —. - <br /> II PLAN CHECK FEE _ $30,00 each'SUBMISSION/RESUBMISSION <br /> F <br /> REPAIR -- -- <br /> IITanks x SII0.00 s — <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> A PIPING P.EPAIP./CLOSURE/P.EMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) _-- <br /> I ---- -- ---- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IIISPECTION <br /> (when applicable) (when applicable) (when applicable) !-_--,_-_- <br /> FEE i30.00/hr $35.00lhr FEE = S75.00lhr f----- <br /> ---L:= --- - _ ----1-- -- - -1--- <br /> -- TOTAL OUE $ <br /> OFFICE USE ONLY <br /> QQIQm.QPQmQQ IQQ11�m1@RQ�QPQQV'19Q999fmJQ,i411� �`QQ�l�md781�Im.VPdii"QQ6Q9QmQ1Q .?nQ�QQ�VQ�IVI�VNIB IIVQV"aQ1Q�IVIIVQ�3QQI I!If�QIVN€V°�m�G111:DDAtTE <br /> VIV4afIIIQQQ!IQI000Q. VQfd��VIQMIV?1fr�aQQVVmj <br /> SWEEPS t- COMP $ LOC CODE GIST CODE AMOUNT DUE AMOUNT Rr,VD CHECK t/CASH Rf,VO DY RECEIVED PERMIT <br /> a„gob I�� Sao p? aII�QIiQ�fuQf�f I i�a�maQ Q� QQQim c�t� QaQ I°�Im Qm f°Q IQQmmcaQQQ QQ � (ulu iQUQQ�I .IQmI�QQll�QmQ�QQQ <br /> E'H i��O� REVf�ED �/88 <br />