Laserfiche WebLink
SAN IOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> !f FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> -t b,� l __� r�_ ---_ <br /> C k <br /> I „•_�-.-_-.._...._._._.-.._...___._.. N/TH AREA COOS <br /> L STREET ADDRESS SITE HONE — <br /> T 5T�T ��,�P CODE 1 0( Tanks <br /> Y CITY �JJtt �j : COD at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> PPL CANT PHONE 1 WITH AREA C00% <br /> I MAI-ING ADDRESS -7 I'>N CITYago <br /> STAT ZIP-CODE TYPE of APPLICATION <br /> CLOSURE. INSTALLATION. ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR - TOTAL <br /> C 1986 1987 1988 1989 -- _- — <br /> V ----- <br /> E TANK FEE $50.00 each TANK <br /> F 1 Tanks x (50.00 1986 1987 1988 1989 _i <br /> A (multipTy_r-by fee for <br /> C each year applicable) $ <br /> 1 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH & SAFETY COD a or applicability) — - <br /> T 1 Tanks x $56.00 1986 1987 _— <br /> Y (enter iiount and year) ---- --- -- f— — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE _ $90.00 each TANK - 1 Tanks_ _ x 190.04 1 �7 �• <br /> S -- -- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to We years) <br /> E-._____ _—__..____.--•-----__ _____.—_--•___-- <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I.Vanks------ x $80.00 $ <br /> PPLAN CHECK (Installation or Re ir) <br /> L <br /> A $ <br /> I-w 3L <br /> 11 PLAN CHECK FEE -- $30.00 each SUBMI IONIRESUDMISSION <br /> REPAIR <br /> P. TANK, REPAIR FEE = $110.00 each TANK 1 Tanks___ _ x $110.00 _ $ <br /> E - - _........._..---... __ ._._......._._........._. <br /> A PIPING REPAIR,/CLOSURE/REMOVAL (Fees are per hour, minim one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (vl►en applicable) (when applicable) <br /> FEE _ $30.00/hr�._..__--.___....... <br /> FEE_-135_00/hrI FEE- <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> SWEEPS I COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT <br /> .. ..............._........... ........... _-- <br /> .... . <br /> .....I <br /> ............ <br /> `�7,'-� I`( ala Gln <br />