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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' UNDERGROUND STORAGE TANK PROGRAM - FEE 'WORKSHEET <br /> F FACILITY/SITE NAME—^-^_--- FACILITY CONTACT NAME <br /> � . <br /> C - <br /> L STREET ADDRESS SITE PHONE I PITH AREA coos <br /> I .2 7 ly, _W_ j 0 — <br /> T - <br /> Y CITY qq TATE ZlP CODE I of Tanks /I <br /> l '(� `1�5•�t3� at Site 7 <br /> A APPLICANTIBILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 MrTM AREA caps <br /> N CITY SATE ZIP'CODE TYPE of APPLICATION - <br /> / CLOltUAE. INOTALLATIQM. Etc. �D <br /> FACILITY FEE = $100,00 each SITE ADDRESS per YEAR TOTAL <br /> A - <br /> C 1986 1931 1988 1989 <br /> i 4 <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanksx 550.00 1986 1981 1988 1989 <br /> A (mu I t i p Ty_I(_b y fee for --- -- ----- ----`- - --'4 <br /> C each year applicable} <br /> I -- — <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25281 for applicability) <br /> T 1 Tanks x 456.00 1986 1981 1908 1989 <br /> Y (enter amount and year) - ---- - -- --- -- '-' <br /> 4 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = $90.00 each IANK 1 Tanks_ _ x 490.00 <br /> U -- <br /> F TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CIOSUF_E FEE = $80.00 each TANY, �I Tanks _ x $90.00 <br /> P PLAN CHECK (Installation or Repair) <br /> Lit <br /> 11 PLAN CHECK FEE _ $30.00 each SUDMISSIONIRESUDMISSION $ <br /> REPAIR <br /> E TANK REPAIR FEE = $110.00 each TANKI Tanks x $110.00 4 <br /> E <br /> P --- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid an plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> 1.FEE = $30.00/hr _ FEE _ $35.001hr FEE = $35.00/hr 4 <br /> TOTAL DUE 4 <br /> OFFfCE USE My <br /> 1@ ll l I�11�11!!I���!�V�'� >l l Ill�l I>UIIIl4G l6��C'�i � 118��51�l�lRiVII, 4P�lI1lI V�� lf! gC111=00 NOTE 10.CSl3milllf 11QIf111118iHUN.I '� IN11111I13IRQII� <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK IICASH RrVD DY DATE RECEIVED PERMIT I <br /> ... _.... �..._ Am <br /> !I�ni��ml�i��� ��I �Vp1pfV41!�1111dipi!I� 1� _ '� . � p �� 6 !� � <br /> r aIRIR� !IO� nen �!q �a!u��ll�!II� Ifll1 <br />