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SAOJOAQUIN LOCAL HEALTH DIOS TRICT UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET FJFACILITY/SITE NAME FACILITY CONTACT NAME .A C �r Hnh L STREET ADDRESS SITE PHONE t WITH AREA CODE T ? S -2- - 123 - Y CITY 1 STAT ZIP CODE 1 of Tanks �/ at Site A APPLICANT/BILLING NAME APPLICANT CONTACT NAME P _ P—— Clr- ,�_ c G a ✓CONTACT I MAILING ADDRESS APPLICANT PHONE t NITN ARCA coot C p_ p A'a O - S =200 0 N CITY , STAT ZIP'CODEfTLYPE of APPLICATION T y� L - 8URE. IMB TAILATION. ETC. C/O v r �b FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL A -- -- _ C 1986 1987 1988 1589 T V $ E TANK FEE = $50.00 each TANK ----------------------- ------- ----- F 1 Tanks _ _ x $50.00 1986 1987 1988 1989 A (multipry i by fee for ---- — each year applicable) $ I — L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) I -- T 1 Tanks x $56.00 1986 1987 I9B8 1983 Y (enter iiolint and year) --- C PERMANENT CLOSURE (Removal or Closure-in-place) L ---- 5 CLOSURE FEE = $90.00 each TANK 1 Tanksx[ 130.00 1 u U R TEMPORARY CLOSURE (Only alloyed one tine for up to two years) E -- TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x 180.00 f P PLAN CHECK (Installation or Repair) L A (N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ REPAIR P. TANK REPAIR FEE = $110.00 each TANK I Tanks x $110.00 f E - -- ----- — --- -- P --- -- A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) I — - R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION (when applicable) (when applicable) (when applicable) FEE = $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr — f TOTAL DUE $ OFFICE USE ONLY AN Nil igiffiliwall Owl SWEEPS A COMP I LOC CODE IST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVEDPEP.MIT t