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-TUL. -- 26-- 4q W EI? 1 4 ! OL?. E PETROLEUM P _ i5 <br /> SAN JOAQU It N LOCAL HEALTH DISTRICT <br /> . UNDERGROUND STORA8f TANK PROGRAM - FEE VORKSHEET <br /> ___...__-_..._.•._ _.._.. _�__... ^--------�_..__�___ FACILITY CONTACT NAME <br /> F FACILITYISITE NAME <br /> I — - - SITE PHONE 4 MIfN A4�A GOOL <br /> L STREET ADDRESS - - 20 -z.3 - -2 7 7 <br /> T -- --".,'. STAT t_P CODE 1 of Tanks <br /> Y CIdY MArvL�4 � X15 33 at Sita ���` —._ <br /> A APPI,ICANTl91LlINfi NAME ____ APPIICAHT CONTACT NAME <br /> P 1'"Y'�Of� Zak �ty J&:2-k' y <br /> P <br /> L "- '-."-- — APPLICANT PHONE 11 wtrM AR[A C00� <br /> I MAILING ADDRESS r 2 7 5 <br /> C �?.cam r3vX�?_......_.... �._....—..._._ ...� ._ zap 83�_21b <br /> .,�...�._.....".–___—- ---. <br /> H C1Ir STATIP'CODE TYPE of APPLICATION �� vA� <br /> �...� - G � � e�aw+t, tN�TA46AfldM, sTC, <br /> 53 <br /> T E3/yvj ?./ - _.....__.-...w__.._ <br /> - __..•.._._ TTOTAL <br /> FACILITY FEE • s104.00-each SITE ADDRESS per YEAR p <br /> A 1986 1981 1988 1989 <br /> E TANK fEEr= 150.00reach TANK t Tanks ... x_950.00 1986 1981 1988 1989 , ._. <br /> A (rultipIy-1-by fee for -------'�- 1 <br /> C each year applicable) - - _ <br /> L STATE SURCHARGE % 156.00 each TANK (set CA HEALTH 1t SAFETY CODE Sec 25281 for applicability) �- -- <br /> T 1 Tanks ,x 156.40 1986 .� 1981 1988 1983 <br /> Y tenter ii56t and hear) -.- <br /> i <br /> C PERMANENT CLOSURE (Resoval or -Clowre-in-place) <br /> 0 CLOSURE FEE = 00.00 each TANK -1 Tanks_., x 1'4.00 1 0 <br /> uRARY~CLOSURE (Only allayed one time far up to two years) —s � �- M--- <br /> R TEMPORARY _ _ _�---- <br /> E�IEhPOP42Y-CLOSURE FEE }_ 180.00 each TANK <br /> P PLAN CHECK (installation or Repaid _ ._ �.r._.._._� _ __....•_�._.. -_ <br /> A i <br /> N PLAN CHECK FEE 130.000 each SWISSIONAESUEniSSiOM� <br /> REPAIR <br /> R TANK REPAIR FEE - i110.00 each TANK --TY-. .. Tanksw �^x 111400 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, einieue one hour to he paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> When applicable) (when applicable) (vhen applitab3e) <br /> FEE - 130.00/1irL_�-_. FfE.-L..$35_09/hri. -.�, r�.- FEE = 13S_,4011+r�� <br /> __...._ TOTAL 'DUE # <br /> pFF1tF tlSF OAtr . <br /> t11111M1 °` M R, <br /> SLEEPS i COMP II LAC Cfl0 T CODE AMOUNT DUE AnOUNT RCVD CHECK 1/ H RCVD DY DATE RECEIVED PERMIT Jy <br /> M ?" 1' 7 'J�7.�! <br /> � 4 �"JI IMO• I J. I• ..i4^^.hCl1b <br /> � <br /> �(� u F 4 ;dl ] "al ..4•u "s. f y 'rld w: <br />