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JOAQUIN LOCAL HEALTH.ISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> 1AllFrFAC[LITY/SITE NAME FACILITY CONTACT NAME <br /> L STREET ADDRESS — <br /> Z bSITE PHONE 1 WITH ARCA CODE <br /> T A UN` <br /> Y CITY I STATE ZIP CODE 1 of Tanks <br /> at Site <br /> A APPLICANPILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L.. cr__ �- <br /> [ MAILING ADDRESS -' — <br /> A Z70 QN r of . Ivd •- — APPLICANT PHONE w1iN ARDe <br /> C _ /S /- <br /> T CIT ` STATZIP}'C�ODE APPLICATION <br /> -- "-- '1� �('S, ✓ ' SCO �--�,-L-LS�A G CLOCYR , INCTAlLAt 10N, CTO. D <br /> FACILITY FiE _ (100.00 each SITE ADDRESS per YEAR — <br /> ATOTAL <br /> C 1986 1987 1388 1989 <br /> T <br /> E TANK FEE _ (50.00 TANK <br /> each <br /> c <br /> F 1 Tanks x $50.00 1986 1381 — 1988 1989 — <br /> A (multiply f-by fee for -- <br /> C each year applicable) - $ <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH d SAFETY CODE Sec 25281 for applicability) <br /> T 1 Tanks x $56.00 1386 1987 1988 1989 <br /> Y (enter aiolint and year) _��— <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — <br /> L _ �►_+oy <br /> 0 CLOSURE FEE = $'90.00 each TANK 1 Tanks _ x (90.00 f pp <br /> S --- _ _— —=1- 90 <br /> U _—--- --- `_ _ <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E' <br /> TEMPORARY CLOSURE FEE = $80,00 each TANK 1 tanks— x 480,00 f <br /> P PLAN CHECK (Installation or Repair) —�-- <br /> L -....._.—._—- --- ------ <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUDNISSION $ <br /> REPAIR -- -- <br /> P. TANK REPAIR FEE _ $1(0.00 each TANK <br /> 1 Tanks x $110.00 f <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) — <br /> FEE = $30.00/hr[ r <br /> FEE _ $35.00/hr FEE _ (35.00/hr $ <br /> TOTAL DUE f 90, <br /> OFFICE USE ONLY <br /> VIII!'1!4!Ipp!II�IIICIVNVVIVIVV1V11�1!!!IVV11!I!111!!1�1'IV1VV11Vp1IVl�J11iIV!V!IINVVVV9VpVl11u1i'I�VI�fiVIlVfi!11iIIViIpIV!IV1!�@fdlVp�IVI@!!191!!�li��"'l�llp�!!;�V3N�' �11i01@allluul!IIIIIi,.la1ufVVIIC.pVVVI�VV9CV!�.I��Iprllr!I�mllp!p�pppl„m�il�llu�l�!IVJ�IVIIVVV� <br /> SWEE �1 C COMP IR LOCO CODE 01ST CODE AMOW DUE AMOUNT REVD CHE€T (ASH RfVO DY DATE P,ECEIVEO PERMIT—t <br /> TIREI'Vap ilig �IdIiNLiI? '!1111V�IVVI�IIiVPI�'NVIV9i1111pG11p 'I !VIp�VIiI�IN 9VIVIPJIIIVVG7'VVIIIVI Np IVfJVVII!IVflI!pII �IIV�l�lllll@plliiVllM!IAVVV9 ,IIINI��p61VVIIVIIVIVp�11VVVlli!Ih <br />