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5A ' JOAQU I N LOCAL HEALTH TR I CT <br /> \ J WNDERGROUND STORAGE TANK PROGRAM - FEE WORK V �� <br /> ' �FFACILITFACILITY CONTACT NAME <br /> I JY/SITE NAME , �,t �,t <br /> L STREET ADDRESS S TE PHO E f (with Area Code) <br /> T <br /> Y CITY STATE ZIP CODE f of TANK'S <br /> 6eh (A 512 q at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P �/off S. 4 <br /> P <br /> L - <br /> I MAILING ADDRESS APPLICANT PHONE $ (with Area Code) <br /> Cr <br /> A <br /> N CITY ST TE ZIP CODE TYPE of APPLICATION <br /> T 1,d/3 1.1 L� (Closure, Installation, etc.) A <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1586 1987 1588 1989 <br /> T <br /> I $ . /D196 <br /> E TANK FEE = $50.00 each TANK <br /> F $ Tanksx $50.00 1986 1987 1988 1939 <br /> A Ti -by fee for <br /> C each year applicable) <br /> I <br /> L STATE SURCHA E = $56.00 each TANK, (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I - <br /> T f Tanks__ x $56.00 1986 1987 1588 1935 <br /> Y (enter amount and year) <br /> .f U oy <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> S $ Tanks x $90.00 $ <br /> ----- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK $ Tanks x $80.00 $ J <br /> P PLAN CHECK (Installation or Repair) , <br /> L <br /> A "— <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ U° <br /> R REPAIR <br /> E TANK REPAIR FEE _ $110.00 each TANK f Tanks x $110.00 $ <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE = $35.00/hr $ <br /> TOTAL DUE f � =J <br /> OFFICE USE ONLY <br /> R <br /> 7SWEEPSCOMP h LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD HECK /CASH RCVD BY DATE RECEIVED PERMIT t <br /> ��il •1fFs!�{i F1��'. 1 ..'A�':`: :... .''-}'i :'..:'�'�/- <br /> 660-z � I jft,! <br /> y. ^` <br />