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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> IF FACILITY/SITE NAME FACILITY CONTACT A//NAME <br /> 1 - - '.. 1-T 7rn R r <br /> L STREET ADDRESS SITE PHONE t WITH AREA COmm <br /> 1 r7 <br /> T 609) <br /> Y CITY STAT ZIP CDDE' I t of Tanks <br /> _Sf cc.Kto. C 4 9S z u at Site PAYMENT <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> q <br /> P/ Q E= M1nqon , factyrrn :R 3 0 0 <br /> I MAILING ADDRESS -' APPLICANT PHONE 1 HIT- A <br /> A 12. /3C-'K U9 -- Ft 1 B M'NfALI EIALI DIVISIO <br /> N CITY y STAT ZIP'CODE TYPE of APPLICATION <br /> _ ,S/ UC K fJ^-_--,_ CR 9 �' O CLOSURE. INRTALLATIOW. ETC. <br /> fFACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A .. -- -- --- — - <br /> T 1986 1987 1988 1989 <br /> I 1 <br /> V <br /> E TANK FEE = 550.00 each TANK <br /> F 1 Tanks x 150.00 —1986 1987 1988 1989 <br /> A (multiply-1 by fee for <br /> C each year applicable) 1 <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH i SAFETY CODE Sec 25187 for applicability) <br /> I — <br /> T 1 Tanks 1 156.00 1986 1987 1988 1989 <br /> Y (enter iiount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L ---- <br /> 0 CLOSURE FEE = 190.00 each TANK <br /> S 1 Anks__J__ 1 190.00 f '= <br /> C• <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 $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> A <br /> H PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f pp <br /> REPAIR <br /> R TANK, REPAIR FEE = 1110.00 each TANK 1 Tanks 1 1110.00 f <br /> A PIPING REPAIR/CLOSUP,E/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 aDDlicable) (when applicable) y <br /> FEE = $30.00/hr FEE _ $35.00/hr FEE = 135.00/hr 1 !I <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> r <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD HECK /CASH RCVD BY DATE RECEIVED PERMIT <br /> los �i of <br />