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S 0JOAQU I N LOCAL HEALTH DISTRICT { . �.-k y 1�Y1` "-a <br /> LZ F C t X F+® <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> { IA FACILITY/SITE NAME FACILITY CONTACT NAME J u L <br /> t <br /> L STREET ADDRESS SITE PHONE $ WIT" AREA coca „rl�rnrr+r r <br /> Y CITY L , STAT IIP CODE $ of Tanks �J <br /> G} at Site <br /> AA APPLICANUBILLING NAME APPLICANT CONTACT NAME <br /> ?-Oog4ev N A6S -__- _ .l®HN <br /> I MAILING ADDRESS 2 APPLICANT PHONE 1 WITH AREA Coca <br /> C p0 Nla ( _ 4l5)�kb1 ��890 <br /> N <br /> CITY STA 2IPCODE TYPE of APPLICATION <br /> _ 29 CLOGME. INSTALLATION. ETC. <br /> FACILITY FEE _ 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 1 �} m <br /> E TANK FEE = $50.00 each TANK - <br /> F $ Tanks x $50.00 1986 1987 1988 19 <br /> A (multiPril -by fee for 9 ID <br /> C each year applicable) — -Z� i---_--- — --_ <br /> I -z Q o <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 fur .applicability} <br /> t __ <br /> T f Tanks _ x 156.00 1986 1981 (988 '1189-- <br /> 4 <br /> Y tenter amount and year} — - <br /> 2-4 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L _ <br /> 0 CLOSURE FEE a $90.00 each TANKS- <br /> U — <br /> P, TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK 1 Tanks x 190.40 <br /> P PLAN CHECK (Installation or Repair) <br /> 11 PLAN CHECK FEE = 130.00 each SUBMISSION/RESUDNISSION $ '2,U <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> E I ' Tanks _ __ x 1110.00 $ <br /> P __ __. _ <br /> WIPING 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 /> FEE - 130.00/hr FEE - 135.00/hr� FEE - $35.00/hr <br /> TOTAL DUE f 9 <br /> SWEEPS f CONP 1 LOC COOS DIST CODE AMOUNT DUE AMOUNT RCVD CHECK !/CAST�r <br /> Y DATE P,ECEiVtO PERMIT f <br />