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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME ---�--�-----�--"`—•"-- ----�'� <br /> A FACILITY CONTACT NAME <br /> C <br /> L STREET ADDRESS <br /> TSITE PHONE 1 WITH ARCA CORE <br /> YCITY <br /> STATE ZIP CODE I of Tanks <br /> IL -�= at Site 4 <br /> A APPLICANT/BILLING NAME — -- <br /> P APPLICANT CONTACT NAME <br /> F <br /> I <br /> If <br /> ADDRESS —--- <br /> C APPLICANT PHONE 1 war" AREA coot <br /> A --_� <br /> N CITY <br /> 1 STATE 2IP'CODE TYPE of APPLICATION <br /> -�--__ �,—_--- CLOGNNE. INCTALNRION. CTC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> TOTAL <br /> T 1986 1907 -1988 —1989 — <br /> V --- _— f <br /> E TANK FEE _ 150.00 each TANK 1 <br /> F 1 Tanks _ x t50.00 1986 1987 --' <br /> A (multiPTY by fee for —_ 1988 1989 <br /> C each year applicable) <br /> I '`-- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH f SAFETY CODE Sec 25287 for applicability) <br /> I -- <br /> T 1 Tanks x 156.00 1986 1987 — <br /> Y (enter aiiiint and year) __ 1988 1989 <br /> PERMANENT CLOSURE (Removal or Closure in-place) — — <br /> L..— -------.._�-- — — <br /> S0 CLOSURE FEE = 190.00 each TANK 1 Tanks �_ x (90.00 <br /> I — -- <br /> P. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E — __ _ <br /> 1EMFORA.Y CLOSURE FEE $80.00 each TANY, <br /> - —, Tanks^_— x 190.00— 1 <br /> J.P PLAN CHECK (Installation or Repair) — '-- -- <br /> L _—__------ <br /> II PLAN CHECK FEE - 130.00 each SUBMISSION/RESUCMISSION <br /> REPAIR ------ __ <br /> F. TANK. REPAIR FEE = 1110.00 each TANK -- <br /> 1 Tanks— x Sllo.00 f <br /> A PIPING REPAID./CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 --"----- —_._. <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IIISPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE - 130.00/hr� FEE = i35.00/hr -- <br /> FEE _ $35.00/hr 1 <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> B9VV�VIM I �. CVVVIiV Wing .EMBRI ��tlImIVIV fO�iN�I!V��IIV!�I!TuTGGVC �^V9V�GV��IIG�IIV@ �d�VPIUbI� + <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHCCK 1/CASH J Rf,VD OY DATE RECEIVED PERMIT 1 � <br /> --- <br /> Lu S8 ' <br /> �'I ry�� ��I.nA pry�Il I�pll�ryp I�mIryIIN�I�II!m�I��II1 yI rt ��(� / <br /> 2 .1 9iII just �IIYIItl tlYll ll!�:�Y!IQ 11Y1mfaYtlllA1A R951IA1A1 y, I�jllnlh .l MI IR�MIIMm� IRM. Im911lIIeMlin'^I'ImnA rylAn Inmlm�"r'^^Annmmm..nm'..7„ <br />