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SAN JOAQUIN LOCAL HEALTH DIvRICT <br /> _.aERGROUND STORAGE TANK PROGRAM - FEE WORKSHEL,/ <br /> .,r//SIT/E^NAME —/ / FACILITY CONTACT NAME p Py ` r10 <br /> S.111�4l A /r a - Vee om` /ower zvvi nn EC' <br /> ana <br /> L $IR AD SS SITE PHONE 1 WITH AREA COOK 1(� <br /> I r ala- - slSa ►p� Epz <br /> Y CI J \oc f STAT 21P CODE 1 0( Tanks AMEN v E5 <br /> .� F---F+►+r__ -- „d at Site_ � F1���0. t1�5ER <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> i P <br /> P / R/ <br /> I MAI ING ADDR S 1 / APPLICANT PHONE t WITH AREA CODE <br /> ! ' N CITY STATE ZIP CODE TYPE of APPLICATION <br /> I Cc ro I G 7/ CLOeuee, INSTALLATION, ETC. r <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A...— —.._.— -- <br /> C 1986 1987 19BB —1989 <br /> T 98 — <br /> I — — --- — <br /> V f <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks _ _ z $50.00 — `1986 —1987 1988 1989 <br /> A (multiply 1 by fee for -- <br /> each year applicable) $ <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH V SAFETY CODE Sec 25287 for applicability) <br /> I — — <br /> T 1 Tanks x $56.00 1386 1987 1988 1983 <br /> Y (enter iiiiit and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L — <br /> -- <br /> OCLOSURE FEE = 130.00 each TANK 1 Tanks x $90.00 <br /> S _ C <br /> u- _ <br /> R 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 /> L _ _ <br /> A — ---- <br /> N PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUDMISSIONr <br /> REPAIR <br /> P. TANK. REPAIR FEE _ $110.00 each TANK <br /> E 1 Tanks x (110.00 $ <br /> — --— <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I — -- _ <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr fEE = 135.00/hr FEE = 135.00/hr f <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> SWEEPS t COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT t <br /> IBM 19mme OEM= 1""' <br />