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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> S <br /> rA <br /> ___ UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ILITY/SITE NAME FACILITY CONTACT NAME <br /> e Service Station Sharon or C1 de Walther <br /> - <br /> EET ADDRESS SITE PHONE I N[T" AREA coos <br /> 00 West Eleventh Street 209-836-5203 <br /> TAT IIP CODE t of Tanks <br /> acv, CA. 95376 at Site 1 (One)ICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Carl D. Navarra (Owner) for <br /> e Service Station ---- --T- ClydeWallther <br /> ING ADDRESS APPLICANT PHONE t w[T" AREA ME <br /> On WPat F1 P..Enth Gyc 209-386-5203 <br /> STATE ZIP CODE TYPE of APPLICATION <br /> ac CA. 95376 — 01OauRE, [NETAIIAT[ON, ere. <br /> Y`-- -- ----- Closure <br /> FACILITY FEE _ $100,00 each SITE ADDRESS per YEAR --— V <br /> T 1986 1987 1988 1989 <br /> I <br /> X X X 400.00 <br /> E TANK FEE _ $50.00 each TANK r 4 <br /> F t Tanks _1 z $50.00 1986 1987 1988 1989 <br /> A Oultipfy ( by fee for - — <br /> I each year applicable) _- X x x — X $200.00 <br /> _ — __ - <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks y_ x $56.00 198661987 1988 1989 <br /> Y (enter 5iount and year) -- - - -•--}--- l- <br /> 1 X $ 56.00 <br /> C PERMANENT CLOSURE (Removal or Closure-in-pla(e) — - <br /> L .- --.-----_�_._--_— — <br /> 0 CLOSURE FEE _ $90.00 each TANK t Tanks_,___ x $90.00 S <br /> S-- -._— -_ !�^----- 90.00 <br /> E TEMPORARY CLOSURE (Only allowed one time for up to two years) - <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK t Tanks x $80.00 $ <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 /> P, TANK REPAIR FEE _ $110.00 each TANK t Tanksx $110.00 $ <br /> E <br /> P _— -..-- -- ------- T- -- <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 /> - - - - - -- -- --- <br /> FEE _ $30.00/hr FEE $35.00/hr FEE <br /> TOTAL DUE $746.00 <br /> OFFICE USE ONLY <br /> GG!"..3 "1GGIGGIGGIIII!G1G.?!.. ,.9'1G19991T�I�iG�R 9GGGG000GGGGGuGG4 ° uS,GGGGGGGGGGIGII!GGGGGGI'V!GRGI"a GG�INi GGI lig . iGG!Illlltl"iPuTIiGI GGGGGGGGGGNGiIGNO�IG9�IRN9 V�!RGd IIGPGk��G d�GGGj <br /> 6 G .i ,. G <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT t <br /> 11"i �GP1G�K�1� Gilfl'GNViIgGGGGG IP�i�,,,GI IGk I�GI G�I�I!GI!IGGIImim1R.G KnimIIlmnI1GN1 GENIIGGfuMIIIIGGIGr�II�IPI�9GIIIGI!9iVGG!�I��IGGIDnGiIII GIIVG9Gl. !GGI. <br />