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SAN -OAQUIN LOCAL HEALTH DI' -RICT <br /> -odERGROUND STORAGE TANK PROGRAM - FEE AORKSHEEr <br /> FACILITY/SITE NAME N im-VFACILITY CONTACT NAME <br /> C <br /> I <br /> L STREET DORESS SITE PHONE t WITH AREA CODE <br /> I <br /> T <br /> Y CITYSTAT ZIP CODE t of Tanks <br /> �C "�� 9 2 2 at site 2— <br /> A APP <br /> LICA <br /> NT/BILLING NAME APPLICANT CONTACT NAME <br /> I MAILING ADDRESS APPLICAN PHONE t MIiN AREA CODE <br /> C ��t fJ . 4 - 2 <br /> T CITYC�'� \ ST T TIP CODE TYasuof AP�PLICATIONoN, eic. rn <br /> �fJ �lUl" 2 gs2a5 <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1981 1988 1989 <br /> T <br /> I <br /> E TANK FEE = 150.00 each TANK <br /> F t Tanks 2 x 150.00 1986 1987 1988 1989 <br /> A (multipTy-1 by lee for <br /> C each year applicable) BD h s ?fid <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks 'Lx 156.00 1986 1987 1988 1989 <br /> Y (enter mount and year) <br /> s <br /> �Q(o <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> O CLOSURE FEE = 190.00 each TANK 1 Tanks 'Z x 190.00 1 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only alloved one time for up to tvo years) <br /> E <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK t Tanks x 180.00 s <br /> L PLAN CHECK (Installation or Repair) P A Y M EIV T <br /> A <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION s <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK 1 TdmARLd1I SEft� 90 s <br /> E �--- <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHOR17ED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (When applicable) (When applicable) =SAMPLING <br /> FEE = 530.00/hr FEE = 135.00/hr FEE = 135,00/hr f�— <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ZS11 <br /> COMP 1 LOC CODE DIST CODE=DUEAMOUNT CHECK WASH RCVD BY DATE RECEIVED PERMIT t <br />