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SAN JOAQUIN LOCAL HEALTH ISTRICT <br /> �' --UNDERGROUND STORAGE TANK PRO6RAM_ FEE WORKSHEET -- - — <br /> / (FI FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A CA QrIPs /Wca-C'kaY nPSs <br /> C ,gAell o;/ C'O <br /> L STREET ADDRESS SITE PHONE 1 NrTN AREA eoDs <br /> T / 3/3 c . C'lzarfec -. 9 8 - 5�3/s <br /> Y CITY STATE IIP CODE 11 of Tanks <br /> S C/C /-0.-2 C',9at Site �o <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P 4o/Pr' <br /> I MAILING ADDRESS APPLICANT PHONE 1 "'IN AREA emmc <br /> N CITY STATIIP'CODE TYPE of APPLICATION i <br /> �C�Crli rL2.-e fp �DA 5;S.5 75 alDeume, IN/TALLATIDM, ere. 5 1 <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T (986 1987 1988 1989 _ <br /> • 1 f <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks x $50.00 1986 1987 1988 1989 <br /> A (:ultipTy E-by lee for <br /> C each year appli <br /> I cable) I� <br /> — <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 $56,00 1986 1987 1988 1989 <br /> Y (enter H55at and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) _ <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks x $90.00 f <br /> S — <br /> U — <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E - ---_ <br /> TEMPORARY CLOSURE FEE _ $80,00 each TANKs — x $8 <br /> 1 Tank0.00 f <br /> P PLAN CHECK (Installation or Repair) —— —' <br /> U— <br /> A _A <br /> 11 PLAN CHECK FEE _ $30.00 each SUBMISSIO ESUCMISSION f v� <br /> REPAIR <br /> P. TANK. REPAIR FEE _ $110,00 each TANK 1 Tanks x $110.00 $ <br /> P--- <br /> A <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 _ $35.00/hr $ 3 S <br /> c2° <br /> _— .----....... _ _._ _...__.__._._-_ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY �mI 1I p �p I� <br /> lin <br /> �I It��II: 111�� �II� I��I 'Y 1� III �1�11��� i.11i� Illf u � N.7LeoETI II.GG.I`1aNc11 D 'V.GUN,PINCV,u]I� IIPGLJiUuN11V.fiIGI� , . 9 ,GIST CODE AMOUNT DUE AMOUNT RrVD N r /rASN 6rVD DY GATE DECEIVED PEP.M[T t <br /> _ C .._. _.T / Y% O/ 3 �s ... 5 /O z a% <br /> I I�I�Imr l91' r���r,��l! pulNl�giGUi�!Gi �,IN�1 GIN!Glf!P9GNIIINP!G�IflGNIGR!isGIIDdI��:C N�iGIIII �Nl9111mGII�IIGBIIIMU�I@G4mn�m'.19fW� I UIG9i/ roa 'RE1 1 7 <br />