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SAN JOAQUIN LOCAL HEALTH DT —TRICT <br /> �—ADERGROUND STORAGE TANK PROGRAM - FEE RORKSHe{, <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A 'a/ q <br /> 1 STREETT �U s SITE PHONE 1 HIT" AR[A Cooa <br /> Y CITY 5r.bSTATE ZIP CODE t of Tanks <br /> e -vv [7`� at Site <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L -- <br /> I MAILING ADDRESS <br /> t APPLICANT PHONE t WITH ARCA COOS <br /> N CITY — - -- STATE ZIP CODE TYPE of APPLICATION <br /> ,T--------.-- --- --, — e�oauRe, INSTALLATION, ETC. . <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ......_— —._.__.... ------ -- . <br /> C 1986 1987 1388 1989 <br /> T <br /> V -- f <br /> E TANK FEE = 450.00 each TANK <br /> F t Tanks ( x $50.00IN <br /> 1981 1988 1989 <br /> A (multiply 1-by fee for F <br /> C each year applicable) <br /> I .----- _ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH It SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks I x 156.00 1386 1987 — 1988 1983 <br /> Y (enter iiuunt and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — <br /> L ----------— -- <br /> 0 CLOSURE FEE = 490.00 each TANK t Tanks_J x 490.00 f <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E"---- - -------— — — - —TEMPORARY -- <br /> CLOSURE FEE _ $80.00 each TANK 1 Tanks - x $80.00 4 <br /> P PLAN CHECK (Installation or Repair) — — — <br /> IN PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUDMISSION 4 <br /> _ ..._..-------------- <br /> REPAIR - <br /> -------------------------- <br /> F. TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x 11110.00 f <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 = 135.00/hrr FEE = f35.00/hr f <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> 411 iffill =PMIT <br /> SWEEPS 1 COMP I LOC E DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD DY DATE RECEIVED <br /> /fP....__.... _.. ZS <br /> MEW <br /> f7Ysz _ -- --- <br /> r G ., . MISMAM <br />