Laserfiche WebLink
gR+ JOAGWIN LOCAL HEALTH TRICT <br /> *'fDERGROUND STORAGE TANK PROGRAM - FEE NOR <br /> FACILITY CONTACT NAME <br /> F FACILITY/SITE NAME /� / O J <br /> Ct1 tJ _ <br /> I SITE PHONE Y (with Area Code3 <br /> l STREET ADDRESSl 5 �� r{!PZ" S 3 <br /> T STATE ZIP CODE Y of TANK'S <br /> Y CITY 95-7 at Site <br /> �rD N APPLICANT CONTACT NAME <br /> A APPLICANT/BILLING NAME MO <br /> P <br /> P I APPLICANT PHONE 1 (with Area Code) <br /> L <br /> I MAILING ADDRESS S �� <br /> CTYPE of <br /> A STATE ZIP CODE (Closure, installation,N CITU installation, etc.) <br /> T <br /> TOTAL <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR 1188 1989 <br /> A 1986 1981 o c) <br /> C $ <br /> DD <br /> TC) U /00 <br /> V <br /> E TANK FEE _ $50.00 each TANK 1986 1939 <br /> 1981 1988 <br /> F 1 Tanks „ x $50.00 / / $ / 00 <br /> A (multipiy 1-by fee for U/ <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK. (see CA HEALTH d SAFETY CODE Sec :5281 for applicability) <br /> 1 1986 1981 11388 0 0 <br /> T I Tanks x $56.00 $ <br /> Y (enter amount and year) 8 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) f o o^ <br /> L1 Tanks--3_- x $90.00 <br /> D CLOSURE FEE _ $90.00 each TANK <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) ; <br /> E 1 Tanksx $80.00 <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK <br /> P PLAN CHECK (Installation or Repair) <br /> L f <br /> A <br /> N PLAN CHECK FEE _ $30.00 each suBMISSION/RESUBRISSION <br /> REPAIR $ <br /> R Y Tanksx (110.00 <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> SAMPLING <br /> UNAUTHORIZED RELEASE EVALUATION INSPECTION N ION INSPECTION <br /> (when applicable) $ <br /> FEE _ $30.001hr <br /> FEE = f35.001hr FEE = f35.001hr oa <br /> TOTAL DUE f aL- <br /> OFFICE USE ONLY <br /> SWEEPS Y COMP Y LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT Y <br /> i <br /> 2St <br /> L <br />