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SAN JOAQUIN LOCAL HEALTH DISTRICT t/VyC, <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME ^— FACILITY CONTACT NAME <br /> C( <br /> I <br /> I STREET ADDRESS I g S SITE PHONE 1 NIT" AREA COD[ rj o O <br /> T 9 —SS' <br /> 3 -Lf7o <br /> Y CITY STAT UP CODE 1 of Tanks <br /> __ z6 at Site <br /> F APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> P <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 MIT" ARCA coos <br /> C <br /> N CITY _-- -- STATE ZIP CODE TYPE of APPLICATION <br /> T - --_- - '--- CL00YR[.-IMTALLATION, 9TC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR —i TOTAL <br /> A - ---- —__._ — -- .—...---------_......_.. -- <br /> T 1986 1987 1988 1989 9 a/-0 — - - — <br /> V OD —� OC/ (7U foo s SOO <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks x $50.00 1986 1987 1988 1989 l a <br /> A OultipTy f by fee for <br /> each year applicable) <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 1981 1988 1989 <br /> Y (enter almount and year) S6 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) -- — <br /> L <br /> 9 CLOSURE FEE = 190.00 each TANK �— 1 Tanks___ x $90.00 f g d <br /> N . <br /> P. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E ----- - <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $90.00 $ <br /> P PLAN CHECK (Installation or Repair) —~— <br /> L ----- —— _—--- — - —_ — — — <br /> A - <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION f <br /> .... .REPAIR '----------------------•--- -- ---- --- <br /> R TANK REPAIR FEE = $110.00 each TANK Tanks — x 1110.00 - <br /> E <br /> A PIPING REPAIR/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 INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE <br /> TOTAL DUE f 6,oa <br /> OFFICE USE ONLY <br /> N�15IAININE 3101111111i1111ai'I!IP,1111111?11Tu11illIG9i�1V111'J1CV!�JIii11G1PtJV@NWWVMVI�VI�IIdI�!!El�l�u� <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD Y DATE RECEIVED PERMIT I <br /> ........_. <br /> i Imry�r q I'. . I try1���mtppm!i1181L�IfiV1� "111P11GIi1:1iH1111@11�!1111�"!�GII tllfgl'llililll9l!Ifl11111g1illlill 11�J!11CIII1011111111111Pt'""`911111iP1U11i11i1n111� 111111111111!11191.1111!V1ryl111!IWplliPi111A1111VIPI�PVI;VVll1i11u� <br />