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•Jf_iL 2PS--S W ED 1 0F.E PETR0LEi_1M <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET _ <br />F FACILITY/SITE NAME _ — u FACILITY CONTACT NAME <br />A ,�. 2 -1 K. rz "?-'r Y`-rj C -C <br />C / t <br />% $2 4 �'lJ r. S � X X UN _._ <br />I -' — SITE PHONE t M{TM AR[A eoo[ <br />L STREET ADDRESS _ z vy Q, 3 - -7 <br />T "- _ STAT IIP CODE t of Tanks <br />Y CITY C15-3316 at Sits r-OJ�Z <br />A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br />MAILING ADDRESS <br />i:� v. ac2X G7 <br />CITY 13 4y <br />FACILITY FEE : $100.00 each SITE ADDRESS per YEAR <br />C--- ___._-- <br />T <br />I <br />P - 4n , <br />i a✓>Z iz Y rho c-Iz L <br />APPLICANT PHONE t M{TM A` coo[ <br />STAT IIP'CODETYPE of APPLICATION I Moi A L <br />C11 30 L) CLOAUR[, {N[TALLA1109, [TC- -- <br />__..••1986 -1981...1988 -- - ----1989 <br />E TANK FEE % ISO M each TANK <br />F t Tanks __ - x $50,00 — 1986 1481 1988 1989 <br />A (multiply 1 by fee for <br />C each year applicable) — w ___.— ,—_ <br />L STATE SURCHARGE = 156.00 <br />each TANK (see CA <br />HEALTH L SAFETY CODE <br />Sec 2529) for <br />applicability) <br />I—__._..,._.._-----�--• <br />T 1 Tanks x 1 <br />Y (enter iiount and year) <br />- - <br />1986 <br />�' <br />198156.00 <br />-_ <br />1988 <br />� <br />1983 <br />— <br />PERMANENT CLOSURE (Re-loval or Closure -in -plate) <br />CLOSURE FEE _ $10.00 each TANK <br />TEMPORARY CLOSURE (Only alloyed one time for up to tvo years) <br />TEMPORARY -CLOSURE FEE : $80.00 each TANK <br />1 Tanks___ x $600.00 <br />TOTAL <br />I Tanks x $80,00 - J <br />P PLAN CHECK (Installation or Repair) <br />A $ <br />N PLAN CHECK FEE-- $30-00 each SUBMISS(0)(/RESUBMISSION_ <br />REPAIR <br />C TANK REPAIR FEE = $110.00 each TANK 1 Tanks_ -• x $110.00 $ _ <br />E <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) --- — - <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTIONINSPECTION~� SAMPLING INSPECTION <br />When applicable) (when applicable) (vhen applicable) <br />= r FEE _ $35.00/hr $ <br />FEE_- FEE $35.00/hr---�� <br />$30.00lhrt----__•--- — <br />TOTAL DUE f 70 <br />OFFICE USE ONCY <br />SWEEPS 1 COMP 1 LOC CODE CODE AMOUNT DUE 1. AMOUNT RCVD CHECK 1/C-" RCVD DY I DATE P.ECEIVED PERMIT e <br />'YY n ! !!l✓/ N `i �i-�1G✓!/ ./ V _—_ �L AJ�L. <br />MY.*Ilnnl�•', ^,►!F,fi;'bi•ngn! <br />