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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> --UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET - _--- <br /> F�FACILITY/SITE NAME FACILITY CONTACT NAME ^ <br /> A- ------ ` \� <br /> ISITE PHONE t WITH AREA COOK <br /> L STREET ADDRESS <br /> Ij YU _,\ <br /> T- — <br /> Y CITY STATE IIP CODE 1 of Tanks <br /> --�--- -- at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P W E_5y, <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA COOK <br /> I- ""a-`-1 35 V _____ _ <br /> A- <br /> k CITY STATE ZIP CODE TYPE of APPLICATION <br /> T—. C' lL.—_ cLoaunE. INETAUATIntl. ETC. <br /> IA FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> (987^ 1988 --1583-�-- f_- .---- <br /> 1986 ---- <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanksx $50.00 1986 1987 1988 1989 <br /> A (multipTy_I_by fee for - -- ----- - ----- - <br /> C each year applicable) — S <br /> 1 ----- - <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x $56.00 1986 1987 1908 1383 <br /> Y (enter aiouot and year) --FaME �--- <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L ---- - ----- --_- ---_.. --..- --- - -- --- <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks SAmw UIf1 <br /> S _-.-- -__;- - --Ptl Al <br /> H SERVIC S <br /> U ---- - ---- thE <br /> P TEMPORARY CLOSURE (Only allowed one time for up to two years) ENV I <br /> E - -- -- -- ------ --- -- <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK =-I-an 80.00 Is 9 <br /> P PLAN CHECK (installation or Repair) <br /> L --------.._--------------._.._-_._:..------ ---------.__...--------.---- <br /> A <br /> If PLAN CHECK FEE - 1130.00 each SUBMISSION/RESUBMISSION <br /> ---_ $ <br /> REPAIR <br /> P. TANK REPAIR FEE _ $110.00 each TANK t Tanks x $110.00 f <br /> --- - <br /> P -- --- -- --.------------- - -- - -- - _ --_.. <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 /> FEE = $30.00/hr FEE _ 13J.00/hr FEE $35.00/hrl $ <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> RI�1�&^ VV9pIB9GVIIVll! �JVIG��Nh'9VG!IfJ 19f�fW1191GVVE9I�VQVIIiiiV9l�lVClla",I�1111i1�G1Vi."! IVVGOVVViVV191!�VVVVI' IVur1' 'G�'I�GVGG1111VIQIpiIfV�J!VIIIl71'.';�fliV IiIV�VIIV7JGVV!flVililfl1RUIVu�IVMJ!VVIVVIG10,1Gi11"IfVVa�j <br /> SWEEPS 1 COMP t L0� CODE DISI CODE AMOUNT OUE AMOUNT RC4B CHECK WASHRr,VD BY DATE P.ECE14E0 PEP.MIT e <br /> -. _.. - ------ <br /> ..- ---..._ - .— --- <br /> 4�1/$1I4pp�����r71�rIJ�pI„II 9 pNVIiVVf"�VrV 1iG,4'�IPJBI�GVGII:! . VVVIVVI'PV11",!Vllnd�lallu�J@�IVIIVVhI�:C IIJ�I�VVGVI!99111V�1:VC0tl@I 'IVf�119 VGP�IINVI��IVVVIVVI'JC .V111VV9PJiJG�f GV�'J09MIM�!VIJVVV <br /> E'1 I7'OOTPEVTSEU C2�9b <br />