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i <br /> c SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C A7 l \/J 1 c�C f <br /> L STREET ADD RESS1 SITE PHONE 1 erre Amu CORE ��qL — <br /> 11 DF 6 <br /> Y CITY �� , 11P CO� 1 of Tanks <br /> cam'\ 6CO at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P �� � � � �r-`` tt ,,••ff <br /> P ck C�,�C 1C�— Tw �C� 1K LC7CE — <br /> L -SLIM APPLICANT PHONE 1 etre AREA CODE <br /> 1 M !r ADORESS — — - <br /> A '` <br /> N CITY STA TIP CODE TYPE oT APPLICATION <br /> I 4S3o� C�meuee, uarrauurar, ere. ec C <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ..- - — ----- <br /> T ---1986 ^1987 1988 —1989 <br /> V - <br /> E TANK FEE = 150.00 each TANK _ <br /> F 1 Tanks __ - x (50.00 1986 7I' 19W 1988 1989 <br /> A (eultipfy 1 by lee for -- <br /> C each year applicable) <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 15181 for applicability) — - <br /> T 1 Tanks x 156.00 -- 1986 1987 1988 1989 -- <br /> Y (enter !RW and <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) I <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 tanks_ z {90.00 1 �Q <br /> U - ------ <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) -- <br /> E TEMPORARY CLOSURE FEE _ {80.00 each TANK — --TI Tanks _ x $80.00 -- 1 <br /> P PLAN CHECK (Installation or Repair) -- <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION - <br /> REPAIR <br /> R TANK, PEPAIR FEE _ $110.00 each TANK 1 Tanks______ 1 1110.00 { <br /> P_ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on pian submittal) <br /> I --------- ------ <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IfISPECTION <br /> ](when applicable) (when applicable) (when applicable)_._.._._le)--------._. .-... ---- -- $ <br /> FEE _ $30.00/hrL FEE = 135.00/hr FEE <br /> TOTAL DUE <br /> OFFICE ISE 011y <br /> SWEEPS I COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT KCVO CHECK 1/CASH RC VD DY DATE RECEIVED PERMIT 1 - <br /> K3v _ ...... __-- ---� _. <br /> .i <br />