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PAN JOAQUIN LOCAL HEALTH DARICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE VORKSHEET <br /> FACILITY CONTACT NAME-Y) )IJ, <br /> cITY/5111 NAME <br /> SITE PHONE I W11" AREA CODE <br /> L STREET ADDRESS C�) fir, <br /> L STREET <br /> E <br /> I <br /> T STATE 4 lip CODE 111, of.7anks <br /> Y Cil at Site <br /> 6NAPPLICANT CONTACT NAME <br /> A APPLICAX/iISILLING NAME <br /> P ryi',�, <br /> L APPLICANT PHONE I NITM ARlR Cool! <br /> 11 <br /> 1 I3G ADV <br /> t�SS <br /> A <br /> city STAT TIP GORE TYP f�AFFLICATIUN <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> A .1986—7 <br /> 1997 1908 <br /> E TANK FEE 150.00 each TANK ------- <br /> - --. <br /> F i Tanks x 1150.00 97 -ZIL <br /> A (sultipTy-l'by let for <br /> c pith year applicable) <br /> L STATE SURCHARGE 2 156.00 each TANK (see CA HEALTH It SAFETY CODE Se( 25201 Tsy ppl,kcabilit <br /> I I tints <br /> t5G.00 1386 1107 ling <br /> Y tenter iiiW and year) <br /> C PERMANENT CLOSURE (Removal or Closure-In-place) <br /> L <br /> 0 CLOSURE FEE - 110.00 each TANK <br /> U <br /> P. TEMPORARY CLOSURE (Only illoved one time for up to tvo years) <br /> TEMPORARY CLOSURE FEE z 100.00 each TANK <br /> P PLUM CHECK (Initillation or Repair) <br /> L <br /> 11 PLAN CHECK FEE it 130-00 each SUBIISSION/RESUDMISSIDII <br /> REPAIR <br /> 11101.00 <br /> R TANK REPAIR FEE 1110.00 each TANK <br /> __—R j <br /> I links <br /> —------ <br /> A, PIPING REPAIRICLOSUREIREMOVAL (Fees are per hour, minimum one hour to be piiS on plan submilON <br /> I —I JO,4QLIIA <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLIHrj 111"ap gryljMj, C tj, <br /> COU/Vr� <br /> VftAIMEAtf�,---J' SO?'VICES <br /> when applicable) When applicable) when applica <br /> FEE <br /> FEE FEE 115.001hr <br /> TOTAL DUE <br /> arrict Iff Doty L-94 t LI-C J pe,tiff mum <br /> MP LOC CODE DIST COOL AmOU111 DUE AftO01 Rryo HEr ItASH 1'%'FVD Uy Uhl[ PICEIVED Whit i <br /> • <br /> 15 1? <br />