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SA. . JOAQUIN LOCAL HEALTH ls"aSTRICT t <br /> r— ----_— UNDERGROUND STORAGE TANK PROGRAM - FEE VORKSHEEI \ , <br /> I FACILITY/SITE NAME --- _ <br /> C _ fACIL1IY CONTACT NAME <br /> I NI�F�7t'1;LL DA <br /> STREET ADDRESS N <br /> A <br /> 1 16 MSR 0v\.)IK) SITE PHONE 1 -1— Ar.. resr <br /> Y City -2D- 3s0 <br /> MAtVTEC10� TATE IIP CODE 1 of Tanks <br /> A APPLICANT/TILLING NAME CA q 53 3� at Site <br /> P SYY�D APPLICANT CONTACT NAME <br /> I MAILING AO ESS --- _ J �-yy)�b`— <br /> r, - <br /> A 3 l w• f-�.C '� _ APPLICAKT PNONQE\1 "'r" A•rs cane <br /> CITY <br /> h1107JrG5g O STAT n lip'tCO—DE i I APPLICATION <br /> �r S3J 1 oru. Mrr����rro�, ■rc,�_ <br /> FACILITY FEE r 1100,00 each Sit[ ADDRESS per YEAR <br /> 1 198619871988 -- TOTAL <br /> _1903 G coo — <br /> V <br /> f TANK FEE • f50.00 tach TANK <br /> f 1 Tanks s 150,00 1986 <br /> / (tullipfy-1-by let for 1387 _ 1908 1993 <br /> C ach year applicable) Int` O <br /> I _ <br /> L STATE SURCHARGE • 156,00 each TANK (set CA HEALTH b SAMY CODE Sec 25287 for applicability) 1 <br /> I <br /> 1 1 tanks s 156.00 1986 <br /> Y (enter iiount and year) 1987 1908 1383 Int@0 -'-- <br /> t <br /> CPERMANENT CLOSURE (Removal or Closurt-in-place) - <br /> L _.- <br /> 0 CLOSURE FEF r 190.00 each TANK <br /> S 1 Tanks Z s 130.09 I <br /> U 1 I8 � <br /> R TEMPORARY CLOSURE (Only allowed <br /> - <br /> E one lin for up to two years) <br /> TEMPORARY CLOSURE FEE r 100.00 each TANK -- <br /> __ 1 Tanks s !80.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L �— <br /> A <br /> 11 PLAN CHECK FEE r 170.00 each SUBMISSION/RESUOMISSI011 --- <br /> REPAIR <br /> R TANK REPAIR FEE • 1110,00 each TANK <br /> PI Tants-^-- s 1110.00 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minitut one hour to be paid on plan submittal) <br /> I - -- _ <br /> R UHAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION(when applicable) (when applicable! SAMPLING IIISPECTION ' <br /> FEE r 10.00/hr (when applicable) j <br /> FEE m 135,00/hr= -- <br /> -- FEE <br /> Of►7U ISE OILY TOTAL DUE 1 a <br /> OEM <br /> !$!F➢IEIR'li " �G�IE1411V1Cr PIdIY° tl©41CylNN <br /> SWEEPS 1 COMP 1 LOC CODE DISI CODE AMOUHT DUE AMOUHT ROD CHECKI/CASHIRCVD Dr DATE RECEIVED PERMIT c F <br /> n � � �l'"'il�'�¢{'ll iC1�7S1�'IIfHIUIT1tt 19TTrglgoHilmEppH lm,.__ ,mml r"nmlMrmmt�e*11m"s�mmr•*•mm�.•,..� <br />