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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />F <br />. .. ........ <br />FACILITY/SITE NAME <br />FACILITY CONTACT NAME <br />A <br />C <br />iG �fap 4 131 <br />azk 6 <br />L <br />I <br />T <br />STREET ADDRESS SITE PHONE # u'TH AREA cone <br />Y <br />CITY STATE 11P CODE I of Tanks <br />J <br />v <br />at <br />C�q Site , -- - 3 <br />P A <br />APPLICANUBILLING NAME <br />APPLICANT CONTACT NAME <br />F <br />L <br />2 e S <br />TANK <br />I <br />r. <br />MAILING ADDRESS APPLICANT PHONE I Hit" AKA COD. <br />.. .............. <br />I Tanks x 150.00 <br />(multiply -l -by fee for <br />each year applicable) <br />1986 1987 1989 <br />N <br />T <br />CITY iTifE F 'CDDE---�PPLICATION <br />tMOTALLATION, ETC. <br />A......... <br />FACILITY FEE = 1100.00 <br />each SITE ADDRESS per YEAR <br />. ..... . ..... ..... .... <br />L <br />TOTAL <br />C <br />T <br />-------------- <br />I Tanks :3 ---- x $90.00 <br />1986 1937 1980 <br />1983 <br />- <br />v <br />R <br />TEMPORARY CLOSURE (Only allowed one time for up <br />to two years) <br />E <br />TANK FEE = 450.00 each <br />TANK <br />F <br />A <br />C <br />.. .............. <br />I Tanks x 150.00 <br />(multiply -l -by fee for <br />each year applicable) <br />1986 1987 1989 <br />1989 <br />S <br />L <br />STATE SURCHARGE = 156.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25297 for <br />applicability) <br />T <br />Y <br />I Tanks x 156.00 <br />(enter ii656t and year) <br />1986 1997 1988 <br />1989 <br />P <br />C1111P�Removal or Closure-in-place)�� <br />L <br />L'.MAN�IT <br />0 <br />S <br />CLOSURE FEE = 190.00 each TANK <br />-------------- <br />I Tanks :3 ---- x $90.00 <br />$ <br />74 D <br />U <br />- <br />PLAN CHECK FEE = 130.00 each SUBMISSION/R-ESUCHIS'alon <br />R <br />TEMPORARY CLOSURE (Only allowed one time for up <br />to two years) <br />E--- <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />— ------- <br />I Tanks $90.00 <br />P <br />PLAN CHECK (Installation or Repair) <br />L <br />A <br />11 <br />PLAN CHECK FEE = 130.00 each SUBMISSION/R-ESUCHIS'alon <br />REPAIR <br />...... <br />R TANK REPAIR FEE = 1110.00 each TANK I Tanks x $110.00 <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br />(when applicable) (when applicable) (when applicable) <br />* ' ----I -- ------ <br />­'' <br />FEE = 130.0�;i FEE 135.0/hr ---FEE = 135.00/hr <br />TOTAL DUE <br />OFFICE USE ony <br />SWEEPS I COMP I LOC CODE J DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I /CASH RCVD BY DATE PECE I 1E1 PERMIT I <br />. ......... . ....... ........... .. .. . ........ <br />