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J!11--- 2-S—P •? W ED 1 1 ? 1,100PE PETR OL—EI-1III <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />F FACILITY/SITE NAME <br />A <br />C XXU/-) <br />L STREET ADDRESS <br />T T - -_--- _. <br />Y CITY <br />UNDER6ROUND STORAGE TANK PROGRAM - FEE WORKSHEET _ <br />�rFACILITY CONTACT NAME <br />2— <br />A APPLICANT/BILLING NAME <br />P <br />P ►� >2i Pr-, 1120LF--U•--j <br />I MAILING ADDRESS <br />r, ►� c7 rjvX G7 <br />CITY <br />SITE PHONE 1 wit" AAtA Coot <br />zo9-S:)�3 --7 <br />STAT IIP CODE ItofTanks - JIZ <br />C -4C15-33(0 Site <br />APPLICANT CONTACT NAME <br />APPLICANT PHONE 1 "IT" ARIA coot <br />2-0q 0 -2 X50 <br />P _ 0 S <br />STAT iIP CODE TYPE o1 APPLICATION /� <br />C11 q/ -30q CLORURt- IMITALLATION, LTC-- (zEMpoAL <br />FACILITY FEE = s100.00 each SITE ADDRESS per YEAR TOTAL <br />A <br />T1986 1987 1988 — 1384 r ---- <br />E TANK FEE + {50.00 tach TANK <br />F 1Tanks _ x 150.00 1986 1987 1988 1989 <br />A (tultiply. I_ by let for -- ---- -- -"- 1 —_• - <br />Itach year applicable) <br />L STATE SURCHARGE = 156.00 each TANK (tet CA HEALTH It SAFETY CODE'Sec 25197 for applicability) <br />T 1 Tanks.___ x 156.00 1986 1987 1988 1989 <br />Y (enter mount and year)__ -- <br />1 <br />C PERMANENT CLOSURE (Re+oval or Closure -In-place) _ <br />L - ---. ; 1 lanks_3__ z 640.00 <br />0 CLOSURE FEE 110.00 each TANK y� <br />R TEMPORARYYCLOSURE (Only allowed one tine for up to tvo years) <br />E-- ---.._-- <br />TEMPORAP,Y CLOSURE FEE - 180,00 each TANK 1 Tanks x 680.00 <br />P PLAN CHECK (Installation or Repair) <br />L...- ---- --- _.__--------._._...._ -- - — - <br />A <br />N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br />1 Y* d -7v <br />s - <br />REPAIR <br />P TANK REPAIR FEE 1110.00 each TANK i Tanks - - x 1110.00 1 <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, sinlaua one hour to be paid on plan submittal) - <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING.111SPECTION <br />When applicable) (when applicable) (when applicable) <br />FEE- J110.00/11rL_`_ _...-�_ FEE�$35_00/hr.lr___ --�... FEE = 13S_00/hr�---- -- 1.. __-•_-....._ - <br />TOTAL DUE f o7 7O <br />OFFICE USE ON(r <br />SWEEPS 1 I COnp 1 LOC CODE DIST CODEI AMOUNT DUE I AMOUNT RCVD I CHECK 1/CASH IRCVD BY I,DATE PECEIvED �_ PERMIT 1 <br />