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SA1010JOAQUIN LOCAL HEALTH bmeSTRICT UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET t t-� A.._.—.-----.--.— C I FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR -- ---_ =._.. _. - -- 1986�-- -1987 1988 1 1989 99 jL F FACILITY/SITE NAME FACILITY CONTACT NAME A f C TANK FEE = 150.00 each TANK L STREET ADDRESS SITE PHONE toom T - Y CITY c (STATE ` ZIP CODDE t of tanks — — JTiaC.�-[�r_I--- A APPLICANT/BILLING NAME APPLICANT CONTACT NAME P T Y P 1306 L _---- I MAILING ADDRESS --------- --- — c APPLICANT PHONE I "'T" •Rme cc=[ A-------•-----. _ _ N CITY STATE 11P'CODE TYPE of APPLICATION CLOIYRCr IMRTIILLRT IONr [TC. I-----------------��-_----- CONSTRUCTION INSPECTION SAMPLING INSPECTION (when applicable) c =° Trm eN (when applicable) A.._.—.-----.--.— C I FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR -- ---_ =._.. _. - -- 1986�-- -1987 1988 1 1989 99 jL TOTAL - -- f 00tr --- 0 CLOSURE FEE = 110.00 each TANK 1 Tanks x (30.00 f E TANK FEE = 150.00 each TANK F A _ f Tanks —_ x 150.00 1986 1381 1988 1983 (multiply -1 by lee for — — 1 E-- each year applicable) L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH It SAFETY CODE Sec 25287 for applicability) T Y 1 Tanks _ x 156.00 (enter iiount and year) 1306 1987 1988 — 1383 -- CONSTRUCTION INSPECTION SAMPLING INSPECTION (when applicable) c =° Trm eN (when applicable) --.---------_.-.._ ... -- ------ FEE = 130.00/1ir - —.._.. -- -—._—_.... FEE = t35.00/hr 36 x ' - — --- --- FEE _ $35.00/hr ----- - - 1 ICI C PERMANENT CLOSURE (Removal or Closure -in-place) -- 1 L-•------------------_--.._-.--------------------------- --- 0 CLOSURE FEE = 110.00 each TANK 1 Tanks x (30.00 f 11 PLAN CHECK FEE = $30.00 each SUBMISSIDNAESUDMISSIOH -- -- f S-- - --—_ U — -- -- --- -- — E-- P. TEMPORARY CLOSURE (Only allowed one time for up to two years) -- E---------- - ----- ------ TEMPORARY CLOSURE FEE = $BO.00 each TANK -- 1 Tanks x $80.00 — f PLAN CHECK (Installation or Repair) 1 L-•------------------_--.._-.--------------------------- --- �P A 1 11 PLAN CHECK FEE = $30.00 each SUBMISSIDNAESUDMISSIOH -- -- f OFFICE USE ONLY SWEEPS 1 COMP1 LOC CODE OISi CODE AMOUIIT DUE AMOUNT RrVB CHECK WASH RCVD BY DATE RECEIVED PERMIT '�;' i REPAIR-----------'----.------- --- P• TANK, REPAIR FEE = $110.00 each TANK1 Tanks x 1110.00 f E-- A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) R UNAUIHORIIED RELEASE EVALUATION (when applicable) CONSTRUCTION INSPECTION SAMPLING INSPECTION (when applicable) c =° Trm eN (when applicable) --.---------_.-.._ ... -- ------ FEE = 130.00/1ir - —.._.. -- -—._—_.... FEE = t35.00/hr 36 x ' - — --- --- FEE _ $35.00/hr ----- - - 1 ICI TOTAL DUE 1�X. OFFICE USE ONLY SWEEPS 1 COMP1 LOC CODE OISi CODE AMOUIIT DUE AMOUNT RrVB CHECK WASH RCVD BY DATE RECEIVED PERMIT '�;' i