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0 & <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />r FACILITY/SITE NAME <br />A IC>ki <br />C 64evrzod S -FA -r <br />FACILITY FEE t $100.00 each SITE ADDRESS per YEAR T <br />1986 1987 1988 <br />-FA—Cl-L--ITYCONTACT NAME <br />A" <br />L STREET ADDRESSSITE <br />ko ?53 PA(:. I F- le— <br />PHONE I WITH AREA C006 <br />..... <br />CLOSURE FEE = 130.00 each TANK <br />tzoc)) 411- 11 <br />Y CITY STAT <br />;TOc*-T <br />TTP CODE I of Tanks <br />at Site �3 <br />A APPLICANTIBILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />P A55oc-1 <br />ZIVICW -Z Z.� <br />L <br />applicability) <br />1 MAILING ADDRESS <br />APPLICANT PHONE I "'I'm AREA cODE <br />c 1,33 -1 Hojw-g---,&,,,�=,:i---. 07-11 Dko lo -4003 <br />A-- - C — <br />N CITY ISTAT d <br />cA <br />ZIP' ODE TYPE of APPLICATION <br />s7ozs— CLOGURE, IN13TALLATION, I!TC/ ,/ <br />A <br />C <br />T <br />FACILITY FEE t $100.00 each SITE ADDRESS per YEAR T <br />1986 1987 1988 <br />TOTAL <br />1999 <br />1 <br />0 <br />..... <br />CLOSURE FEE = 130.00 each TANK <br />E <br />TANK FEE : 150.00 each TANK <br />U <br />F <br />A <br />C <br />I Tanks x $50.00 1986 1987 1988 <br />(multiply -l -by fee for <br />each year applicable) <br />1989 <br />L <br />STATE SURCHARGE = 156.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25297 for <br />applicability) <br />Y <br />Tanks x 156,00 <br />(enter mount and year) <br />11 <br />1987 <br />1988 <br />1989 <br />. . . ......... ........ <br />... . ... . ...... <br />C <br />L. <br />PERMANENT CLOSURE (Removal or Closure -in-place) <br />A <br />0 <br />..... <br />CLOSURE FEE = 130.00 each TANK <br />I I Tanks___-__ x $90.00 — <br />PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSIOtf <br />U <br />(when ap,.Iirable) <br />(when applicable) <br />R <br />E <br />TEMPORARY CLOSURE (Only alloyed one time for up <br />to No years) <br />............... <br />FEE <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />. ........ . <br />--- :D <br />Tanks x $90.00 <br />E <br />FEE $35.00/hrl <br />P <br />L-------- <br />.. .......... -.— . . ... ........... <br />PLAN CHECK (Installation or Repair) <br />A <br />I. ... ....... .... <br />R UNAUTHOP[Itb RELEASE EVALUATION <br />CONSTRUCTION INSPECTION <br />N <br />PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSIOtf <br />S <br />REPAIR <br />TANK REPAIR FEE = 1110.00 each TANK jj7 <br />Tanks______ x $110.00 <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees <br />are per hour, minimum one hour to be paid on plan submittal) <br />I. ... ....... .... <br />R UNAUTHOP[Itb RELEASE EVALUATION <br />CONSTRUCTION INSPECTION <br />SAMPLING INSPECTION <br />(when ap,.Iirable) <br />(when applicable) <br />When applicable) <br />............... <br />FEE <br />"F <br />. ............. <br />-E, E- - <br />.... <br />FEE $35.00/hrl <br />. . . ......... ........ <br />... . ... . ...... <br />------- ... . ......... <br />OTA DU <br />TOTAL E <br />OFFICE W ONLY <br />SWEEPS I <br />COMP I <br />LOC CODE <br />0. WWI <br />DIST CODE <br />19191M. InM.- <br />AMOUNT DUE <br />AMOUNT <br />AMOUNT RCVD <br />CHECK 1/CASH RCVD BY <br />DATE RECEIVED <br />0111M <br />PERMIT I <br />. ...... ........ <br />.... . ..................... <br />I - <br />g111111k. <br />` .... . <br />.... ........ ....... .. <br />