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.._ <br />FIFACILITY/SITE NAME <br />A _ <br />I - <br />L STREET ADDRESS <br />T— Z�4ID L� <br />Y CITY <br />A APPLICANTIBILLING NAME <br />r cfEcxr—F <br />I <br />MAILINIC ADDRESS <br />—�— <br />a7 �u <br />V CITO <br />• 0 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UNDERGROUND STORAGE TANK PR06RAN - FEE WORKSHEET r I <br />FACILITY CONTACT NAME <br />l <br />SITE PHONE t WITH AREA CODE <br />/JctiL <br />STATE ZIP CODE1 tof Tanks <br />__ Com, aSite <br />APPLICANT CONTACT NAME <br />APPLICANT PHONE 1 "IT" AREA Cove <br />is /- Soo <br />STAT IIP 'CODE APPLICATION , <br />SCG n A � G CLO UR IMETALLAf1ON. [T0. x.' / <br />l��l I _ vv K1 1 <br />C <br />L <br />FACILITY FEE _ $100,00 each SITE ADDRESS per YEAR <br />(Removal or Closure -in-place) — <br />la <br />DIST CODE <br />M. <br />AMOUNT DUE <br />TOTAL <br />A._ <br />— -- — <br />— <br />f <br />R <br />E <br />C <br />T <br />(Only allowed one time for up to two years) <br />1986 <br />�l�ll n IV I@9 gill <br />1987 <br />1988 <br />1 Tanks z 1190.00 <br />_ <br />1589 <br />A PIPING REPAID,/CLOSUP.E/REMOVAL <br />1 -- <br />(Fees are per hour, minimum one hour to be <br />paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION <br />CONSTRUCTION INSPECTION <br />SAMPLING INSPECTION <br />f <br />I <br />(when applicable) <br />E <br />TANK FEE = 1150.00 each TANK <br />applicable) <br />FEE = $30.00/hr <br />F <br />A <br />t Tanks_ _ x 550.00 <br />(multiply f by fee for <br />1986 <br />FEE = <br />1981 <br />1988 <br />1989 <br />TOTAL DUE <br />$ <br />f <br />C <br />I <br />each year applicable) <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (see CA HEALTH <br />6 SAFETY CODE Sec <br />25281 for applicability) <br />I <br />1 Tanks x $56.00 1986 <br />1987 <br />1988 <br />1383 <br />Y <br />(enter iii5ht and year) <br />f <br />C <br />L <br />PERMANENT CLOSURE <br />(Removal or Closure -in-place) — <br />la <br />DIST CODE <br />M. <br />AMOUNT DUE <br />5 <br />CLOSURE FEE = 590.00 each TANK 1 Tanks____ x 1190.00 <br />t o m <br />U- <br />f <br />E <br />R <br />E <br />TEMPORARY CLOSURE <br />(Only allowed one time for up to two years) <br />�l�ll n IV I@9 gill <br />TEMPORARY CLOSURE <br />FEE = 580.00 each TANK <br />1 Tanks z 1190.00 <br />f <br />PLAN CHECK (Installation or Repair) <br />PLAN CHECK FEE = 530.00 each SUBMISSION/RESUOMISSION <br />f <br />PAIR <br />FTI�ANK <br />COMP 1_ <br />LOC CODE <br />la <br />DIST CODE <br />M. <br />AMOUNT DUE <br />F, REPAIR FEE = $110.00 each <br />TANK <br />1 Tanks <br />x $110.00 <br />f <br />E <br />'' <br />IC1�?!B��iiT• a s0 @� r� <br />. ' <br />�l�ll n IV I@9 gill <br />iIRTI�l@IIBI T11 F I <br />A PIPING REPAID,/CLOSUP.E/REMOVAL <br />1 -- <br />(Fees are per hour, minimum one hour to be <br />paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION <br />CONSTRUCTION INSPECTION <br />SAMPLING INSPECTION <br />(when applicable) <br />(when applicable) <br />(when <br />applicable) <br />FEE = $30.00/hr <br />FEE = $35.00/hr <br />FEE = <br />1135.00/hr <br />$ <br />TOTAL DUE <br />$ <br />OFFICE USE ONLY <br />SWEEPS 1 <br />COMP 1_ <br />LOC CODE <br />la <br />DIST CODE <br />M. <br />AMOUNT DUE <br />AMOUNT RCVD <br />CHECK 1/CASH <br />RCVD DY DATE RECEIVED <br />PERMIT I <br />dl M m l IPJ <br />36 <br />'' <br />IC1�?!B��iiT• a s0 @� r� <br />. ' <br />�l�ll n IV I@9 gill <br />iIRTI�l@IIBI T11 F I <br />