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r �V JOAQUIN LOCAL HEALT*ISTRICTN vV UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET 1v FACILITY/Sit[ NAME r t FACILITY CONTACT NAME 1 L STREET ADDRESS SITE P ONE WITH AREA teem Y CITY FS ST TF IIP CODE 1 of Tanks at site 6 n'e AA APPLICANT/BILLING NAME — �'� �r�J APPLICANT CONTACT NAME P .. _—L�LK�rL (K�ef P C c p I MAILING DRESS APPLIC HT P N 1 YITN AREA Cone 1� c,�slco b�u�Qs_ 6 2_ _ N CITY STATE ODE TYPE of APPLICATION eweume, INC TAllAT10N, eye. FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR. - TOTAL A —------- — - T - _ 1 _ E TANK FEE = 150.00 each TANK F 1 Tanks x icable 1996 1987 1388 1983 A (multipiy-1-by fee for --- ---- -_-_-- I each year applicable) L STATE SURCHARGE 2 156.00 each TANK (see CA HEALTH 5 SAFETY CODE Sec 25287 for applicability) T 1 Tanks x 156.00 - 1386 1987 1388 1983 Y (enter N56nt and year) C PERMANENT CLOSURE (Removal or Closure-in-place) - Lgo cSV 0 CLOSURE FEE r $90.00 each TANK t tanks x (30.00 1 - T - ------ -- R TEMPORARY CLOSURE (Only allowed one time for up to two years) E TEMPORARY CLOSURE FEE n 180,00 each TANK — 1 tanks s I80 OQ f P PLAN CHECK (Installation or Repair) —— — - -- H PLAN CHECK FEE C 130.00 each SUBMISSION/RESUDMISSION 1 REPAIR - -- -- - -- P. TANK REPAIR FEE . 1110.00 each TANK t Tanks : fI10.00 f E - - -------�=•. ------ _.._ -_.__-----_.---_._.....-._._.__._ A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hourr minimum one hour to be paid on plan submittal) R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION (when applicable) (when applicable) (when applicable) FEE _430.00/hr - FEE = 135_00lhri'-_ _.-_......._.. FEE C 135_00lhri.-...... —_ { -- -- -- - TOTAL DUE OFFZCF• D9E #fly - SWEEPS 1 COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK )/CASH RCVD BY GATE RECEIVED PEP,MIT $ 1 -------- I5. _... - -