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SAN JOAQU I N LOCAL F{F_ALTH DISTRICT
<br /> UNDERGROUND STORAGE TANK PROGRAM
<br /> - FEE WORKSHEET
<br /> A _._._.
<br /> FACILITY CONTACT NAME
<br /> FA FACiL[TYlS1TE NAME ,SIM HOBLITZELL 209)_463 7108
<br /> GAS
<br /> _..._........_. _.... ___-.._.____._......„.._. __...__._.-- SITE PHONE # wtrN AR[A coon
<br /> L STREET ADDRESS
<br /> T ....
<br /> �Q$ __�' .R.IP.QSA......CIA11,._ . � ZCODE t of Tanks
<br /> Y CITY at Site FIVE � )
<br /> FO
<br /> STOCKY©N,......�AL�_....__.__.._._............. _..__......._...... APPLICANT CONTACT NAME
<br /> A APPLICANT/PILLING NAME
<br /> P
<br /> F' UEL SAt`1CNZ . .... ...
<br /> _._.. ._-.- APPLICANT PHONE # WITH
<br /> AREA
<br /> 404!
<br /> l MAILING ADDRESS
<br /> ERSO�I..._'..... ZIP COOP 1YPE of APPLICATION
<br /> ,CIT © {}
<br /> J �V� CLOIURI+� 1KRIALLATtONr [ CLOSURE
<br /> ( tTCCKTON — _ -
<br /> ..._.
<br /> _.__..._.._...._.._..........___...._...._ . TOTAL
<br /> FACILITY FEE #100-00 each SITE ADDRESS per YEAP _.,....._.._.....
<br /> ia86 1987 1a88 1?83 _
<br /> _____. — 100 $ 100
<br /> .. _..........._
<br /> PENALTIES (100%)
<br /> A FEE $50 00 each TANK ..
<br /> E TA las3 109
<br /> 1981 lase
<br /> F 1 Tanks �_ z 150.00 _.. . .-.,....._... .. .._._ ...__._ .._.._.. i
<br /> r
<br /> A (rluI T 1[ b fee for
<br /> 4 _... _.._...._._
<br /> C each year applicable)Y- - _.___.._..._. _,.
<br /> L
<br /> STATE SURCHARGE - 156.00 each TANK (see CA HEALTH b SAFETY CODE Set 25281 for applicability)
<br /> 1 -- 1?8l 1988
<br /> i 1 Tanks-_- 1 556,ff' l 385
<br /> Y (enter aeount and year)
<br /> Ir. PERMANENT CLOSURE (Removal or i lo�ure �n play e) _...._ .. __ ._..----._._...••-_--.___....___...-_--_.-P��-�-
<br /> z
<br /> qL .... _. _..._ .. .,.. ...,. .,.., # Tanks__.,
<br /> 0 CLOSURE FEE %,30.00 each TANk _..._...._.__.._._._._
<br /> _.
<br /> _._.....
<br /> P TEMPORARY CLOSURE (Only allowed one tirle for up to two years)
<br /> w --
<br /> _..... _.__........._.. 1 Tanks x 680 00
<br /> TEMPORARY CLOSURE FEE _ $80.00 each TAN _.._....
<br /> P PLAN CHECK (Installation or Repair) ................_.,......_.......__..........
<br /> )I PLAN CHECK FEE _ $30.00 each
<br /> 4 REPAIR ...._...._...
<br /> _ z $li4 00
<br /> _._..._.__.-.- � # Tanks
<br /> £ TANK PEPAIR FEE _ $110.00 each TAN) -
<br /> E ...
<br /> A PIPING PEPAIP/CLOSUREREMOVAL (Fees are peg hour, mm mum ore hour to be par on plan sub
<br /> I _
<br /> C1lHSTP.UCTION INSPECTION SAMPLING lila
<br /> PECTION
<br /> P ?,NAUTHOP,IdED RELEASE EVALUATION (when apUlicat,le, (when applicable)
<br /> (vhen applicable) _.. .-5.
<br /> FEE $35.00 hr
<br /> EEE $30 nllfhr� EkE 935 001hr� _ .._._..
<br /> TOTAL DUE #
<br /> OFFICE O5E OND'
<br /> r, ���r ,”,� ►I'`11 ��'I!7'j°.144i'.I!Il�!�li���!!I�I!llG!!ij1i11!li il!!!I'�'',!a'lBill!!�II!Ii�111;P,!',11",IIIRl11 I'.I!1�4JI!II!�4!I',liifd'��il�i iillnm�lll'L���!Ifil!Iflli1�11h1,wf�I�N!il �wJ�'df�l�il{!��.��'I,�tiai�!IR��Ii!�,
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<br /> �I
<br /> WEEPS 1 COMP 1 LO1: MODE 9I ST ,:OD€ AMOUIII DILE AMOUHI RIVO CHErY, IIIASH RCVO OY DATE P,€CEIVED PERMIT
<br /> 1,!!i!� �!�!"11' Il'�'11 IIIRi�,ItsllilVlillli1ilp�illll[I�{q��"'�l',li�l,llll�111!i'�I711111�1!�I!II�!IIII!!II!I; 1411�i!nl',Iklllw�!inl�l�lfi� 11114�IaR!f�!114!lill��4!p11,,!�11�k1�!ill!�I!!I�@1QII�!�I!�ll@SII�i41�!��!CiGI�!I�I[I11!II��!U�!il�l!III!i1:1
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