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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> -----.._._._..._............- -- <br /> F1FACILITY/StTE h%ME FACILITY CONTACT NAME <br /> _ <br /> r, <br /> w2s�rn �l�e✓ i <br /> 1 8�J s��GBGdfldl2is✓ ._. � -- - --- <br /> / L STREET ADDRESS SITE PHONE l WITH AREA CODE <br /> Y CITY I STATEI 2110 CODE I of Tanks ��v ` <br /> at Site 2 <br /> A APPLICANT/PILLING NAME APPLICANT CONTACT NAME <br /> P <br /> F <br /> L — 7" <br /> 1 MAILING ADDRESS APPLICANT PHONE t WITH AREA cmmE <br /> A -��.� Lr --� �-✓_�.`_SQL .T .ate - - - Q — - �,& 1/ <br /> T CITY f CTATE� lIP CODE CL08URE.APNBTAALADTNON. ETC. ICE/tt0✓Al <br /> fFACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A -------..--.-.__.._ .._ .. .. ... ------- <br /> 1 �-1386.—I--_-:-1-387- .�- __.-1988---l__-1389-- -�-- f <br /> IE TANK FEE = $50.00 each TANK, <br /> _ -----------...__....-..._.... ._.._......._.... - <br /> ........- ---.. ...... - -- — -- <br /> F f Tanks x $50.00 1986 1`i87 1988 1989 <br /> A (multipTy 11by fee for <br /> - <br /> C. each year applicable) -- - -----_- _...-- - -- --- $ <br /> I -- ---- ---- - - --- -- ---- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH U SAFETY`COOE Sec 25287 for applicability) <br /> T t Tanks x $56.00 1996 1987 1388 1989 <br /> Y (enter mount and year) -- - - - - -- ---- -. -- --- <br /> r PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L —------- --- ......._.-_._..--_. — <br /> 0 CLOSURE FEE = $30.00 each TANK t Tanks ?� x $90.00 $ /✓J�°� <br /> S <br /> U ---- -- -..- ---- --- -- <br /> P. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E ------—.._..-- -- — - <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks__ _ x 590.00 f <br /> --- --- - -- --- - ------------ ----- — <br /> IP PLAN CHECK (Installation or Repair) <br /> LAE --------A <br /> IN PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> P. TANK REPAIR FEE _ $110.00 each TANKt Tanks ____ x $110.00 $ <br /> E -- ---------- - ..._......._.... .-..__.....-................._..__......_..................._..----- — <br /> F - <br /> A PIPING P,EPAIP./CLOSUP.E/P.EMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION -- - -SAMPLING INSPECTI moo <br /> (when applicable) (when applicable) (when applicable) fir' <br /> FEE = $30.00/hr FEE _ $35.00/hr FEE = $35.00/hr 7-ryb f <br /> (/G./( y r y y TOTAL DUE $ U <br /> OFFICE USE ONLY q S. OZD CK D <br /> 999@@00091. @@91@080991@Vi@IIWNBflG9C@@01Nfl1@@flIIP IBI@m@Illlllfll@@@I@Nfl@INNNII@flllVlf�@Illgl@I@IN@INI!GI@@1111@II@MINI@NIIVI@ @N&fll@I@96@@N8V@@N@ <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT P.CVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT t <br /> e IREV ���.°@IO�i901@11991@ II!1411000R+, e11119!II@111!800@N!9111@1@l9!!il J@9111N01@I@I@I!III9B!!I!9i100111@IiIBININ9009B01109@@00111@Im�m,�101@.�11991i91@09910@91!IIN09fl@I�999�u9.�'. @�91�8969�R� <br />