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' SAN`,,,OAQU I N LOCAL HEALTH D lr.4R I CT <br /> UNDERGROUND STORAGE TANK PROGRAM — FEE WORKSHEET <br /> F FACILITY/SITE NAME - FACILITY CONTACT NAME- <br /> . ; <br /> rl �} 1'�LCD _. 7�f�f/US �SSi ons %?oberWhy�-m - Eco. <br /> L STREET AD RE55 SITE P NE # MITH AREA CODE <br /> T _ a ovsf es..__ _ o�� a55'- 96 i4' <br /> Y CITY ��jjSffll '?"i <br /> IIP CODE t of Tanks <br /> S� G rC�� -1a at Site -_.( 3) --� <br /> A APPLICANT/BILLING NAME �^ APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # HIr" AREA CODE <br /> N CITY STATE. IIP'CODE TYPE of APPLICATION <br /> ..i.».__„..........._.....�.—_.__...---.^---.^,...,..._,...,„._..,._..,._.....,.,....,.,,..,.,,,,�__�.,...,.......�_.._._......M... CLOOURE. IHtITALLATiOH, ETC. <br /> �,,.. _..._ <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A --- <br /> C 1986 1987 1988 1989 <br /> I 100 " 1 00 00� /00 -- <br /> VE TANK FEE = $50.00 each TANK <br /> F i Tanks x 150.00 1986 1987 1988 1989 <br /> A (multip y i_by fee for --- _ _ ------ — _ <br /> C each year applicable) r <br /> 3 <br /> -—_T-� _ ._ _ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks x $56.00 _ 1986 1987 1988 T 1983 <br /> Y (enter ali6unt and year) - --- -- --- --- G__ _—.—__ — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE =—$90.00 each TANK --# Tanks x $90.00 $ <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 I Tanks x WIWI f <br /> ......... <br /> P PLAN CHECK (Installation or Repair) <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSIONAESUDMISSION SAN JOAQLJIN COUNTY 1 <br /> ___..____P ti I'AT <br /> REPAIR _ - RMIPIENf1Ct"f3 �T} V -__ <br /> R TANK REPAIR FEE _ $110.00 each TANK # Tanks x 1110.00 $ <br /> p............_. <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one Dour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION - CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.001hr FEE = 135.001hr FEE $3,,.00Ihr 1 <br /> TOTAL DUE f ��! <br /> OFFICE USE ONLY <br /> I a, I�4 is I'L4II itllNllG Ill:llill .'iiMaLIl .,.. a I S�il I ! .iglu M11"!,ilI 01 i i i ilL'A!iS..MI M �I�UII+'W +'�1'IM <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD C CK (CASH RCVD BY HATE RECEIVED PERMIT 0 <br /> .._.........-,............................. _..I_..-.......�...... .lII................11m.f....i..........._......I - <br /> ANI <br /> � . ..,. ,;IIIQILl I.,.l�f� �,Il,��1G�IG►I!��G�,�„�G��,lid,!��GGGR��V�(II l��GlII(�GI!GIgGI S , � ,II pr. ' `�101MI' I I i.... GIC IMI �IG1I RIGGi@�G@IIG�#Ip, �I�!I -;! <br /> Hi <br />