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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _.__-_-,__,__-•._.- --` UNDERGROUND STORAGE TANK PROGRAM- FEE WORKSHEET - <br /> ! F FACILIIYlSITE NAME ___.-_ - <br /> rAPPLICANT/DILLIN6 <br /> FACILITY CONTACT NAME <br /> t <br /> S L <br /> n SITE PHONE 1 ITN ARCA COOK <br /> pSTA�TEC�I(p CODE t of Tanks <br /> "� . �'�.C�-__.� __�_ 7 1at SiteING NAME �APPLICANTCONTACT NAME <br /> RESS(� APPLICANT PH t NIT" AREA COCC <br /> �,p-�-� STATE ZIP'CODE T E of APPLICATION <br /> ___,_ �t'-L-1•.--._—_,__--__.�_� t�LT� �� LO INSTALLATION, LTC. <br /> fACILiTY FEE _ $100.00 each SITE ADDRESS per YEAR _ L - -_---— <br /> rA _ - TOTAL <br /> 1986 1987 1988FEE = $50.00 each TANKks z (50.00 1986 1981 _ipiy l by lee for 1988 year applicable) --^SURCHARfiE = 156.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25281 for applicability)___-_ -ks__ x $56.00 - 19861981 1988 1983 <br /> r mount and year) __ _ - — - <br /> _ <br /> C PERMANENT CLOSURE (Removal ar Closure-in-place) -- <br /> 0 CLOSURE-FEE _ $30.00 each TANK -' - <br /> S t Tanks $ -- <br /> U ... _ _. - _ __ <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years---) <br /> TEMPORARY CLOSURE FEE = f80.U0 eath T7AK -•-----__ __ <br /> - _---_ _ 1 Tanks <br /> HALLP PLAN CHECK (Installation or Repair) ---' -L _-__---___- - --_ <br /> PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> ---- --_�-.-_ Es - <br /> TANK <br /> JE- <br /> REPAIR FEE _ $110.00 each TANK -- - -- -- <br /> $ Tanks__ z <br /> _ - -___..____-_ _ ..__....-... $ <br /> PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour tobe paid on plan submittal) <br /> NAUTHORIZED RELEASE EVALUATIONCONSTRUCTION INSPECTION when applicable) (when applicable) SAMPLING INSPECTION.-.. _.- -_ (when applicable) <br /> EE _ $30.00/hr� FEE _ $35.00/hr-----.__.._._ FEE <br /> TOTAL DUE <br /> OFFICE USF ONLY C>n,•l)[1l <br /> !!Iq'G!G!Iqq„�!IV@�9tlgIIgIIIgGqqq�IG�I't!gl!1114'!gllfl'Igq99Glq!1qGpqq! gglgG�!Gq�lgggqq6il�'IlgggCfi�iG7iqf11qiIII.�G1gil@".d111N;IIGgggG�qlG4qli!!I�gggGq"Vllu�'Vil!Gi�IGIIGiIffiPgliglglai'I!Illgd!�I��,,"44��,,"fIiGVG.g9MIV111ggCV!iG'INilq�lfiJ@IAII!I!IGIigIiI,G!G�61!gllill!Ilfi!!iIG!Ilggiqqq!! <br /> SWEEPS 1 ,COMP,) LOC CODE DIST CO MOUNT OUE AMOUNT RrVD CHECK t/CASH RIY PATE P,ECEIVED PEP.MIT t h <br />