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SAW JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME — — — — FACILITY CONTACT NAME <br /> II e2 ���� �A'HY MR. >ul& LdooD, D <br /> L STREET ADDRESS <br /> 1 7_��O�S(�� Sf SITE PHONE t M TM AREA coot <br /> Tyr'— OgOS^ <br /> Y CIT —— SSpTE lip CODE 1 of Tanks <br /> CAat Site <br /> A APPLICANNT/BILLING NAME <br /> P <br /> — — APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAIL NG ADORES APPLICANT PHONE t <br /> n � �� 5� MITN AREA COY[ <br /> C _ _ _ 9�G--s�sz— �6z� <br /> N <br /> CITYca STATE�— —II CODE T PPLICATION <br /> �� L wauRE INSTALLATION, [re. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR _L TOTAL <br /> C ____ _ --- —.._._—_.. -- — ---- -- <br /> T —I986 _ 1987 1988 1989 <br /> 1 �— f <br /> V- ...- <br /> E TANK FEE = $50.00 each TANK <br /> f t Tanks — _ x 450.00 _— —(986 — 1987 — 1988 <br /> A I uttipTy I by lee for <br /> 1 each year applicable) 4 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I -- <br /> T 1 Tanks x 198S6 1987 1988 1983 <br /> Y (enter ai66nt andndyear) <br /> -- '�A <br /> 1 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) -- <br /> L <br /> 0 CLOSURE FEE = 490.00 each TANK _ — t Tank1x $90.00 f goo <br /> U-- — y <br /> P, TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x 490.00— 4 <br /> P PLAN CHECK (Installation or Repair) <br /> A --- <br /> N PLAN CHECK FEE = 130.00 each SUBMISSIONAESUCMISSION $ <br /> REPAIR ---- ---- -- — <br /> P, TANK. REPAIR FEE = $110.00 each TANK t Tanks x (110.00 f <br /> E ---- ------ <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 _ $35.00/hr FEE - $35 00th f — <br /> TOTAL DUE f <br /> OFFICE USE ONLY — <br /> IIII!@!ICGIII91111VCCACICCCM!N�rCIIICNI!�N!P,IIN4CC999I�11C�IC!I'INIVCdIINIVCIIIiNN1MANJICCiiNCVCC!IIIIICCCIIN �IaiCCCCCiCCCINCCGVIIHIfiI!CCC'!ilfdCICCI�iG!IlifCllMlClai'I!CuiClCllu°I':PufliiillCIJCICIC9CVJ:ICCII�ICC000NIN CCWI�t�I!MVI.CE:IGJCICCCCCj <br /> � � i h ',�J i II � 0 7 q <br /> II I I <br /> SNEEPS t COMP 1 LOC CODE 01ST CODE A AMOUNT RCVD CHECK 1/rASH RCV0 DY DATE RECEIVED PERMIT t <br /> _.... 11. <br /> aI111R 16r161',11191( I�plrNll � ir I' II I / <br /> — — -- -- - <br /> �� NNNIIINNNw.� iIC9Cl � �� _.-_.. <br /> Im'I' � �f�I�11�11 fr��p.C��IuCI�ICCaG 12911CICC118CIIVCIf !. C�INIIVNICID!IGC�IG CP�P�NCBVC1NIVI�NW�r �CI�' IIflCCI�II �IGI�III��INII�CCVC891 CIC!IfiCIroRIICII��IN011Clllh <br />