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SA" JOAQUIN LOCAL HEALTH 'STRICT <br /> '*N" UNDERGROUND STORAGE TANK PROGRAM - FEE NORK\a�lEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> r es i bwz our>-(.ed 0/;le4 1ri;1'j <br /> I STREET ADDRESS D SITE PHONE 1 (with Ar } Code)_ <br /> T l/ <br /> Y CITY � STT 21P ODE Y of TANK'S / <br /> Gq at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> 1 MAILING ADDRESS /5 3 5 A,t ' �1 APPLICANT PHONE t (with Area Code) <br /> C / <br /> A <br /> N CITY <br /> T /�-/ _ ^MATE IIP CODEo S TYPE of APPLICATION <br /> �� Cil lWV C (Closure, Installation, etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 1906 1987 1988 1989 !m <br /> I <br /> v loo — D 0 _ d /DD J $ <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks _ x $50.00 1986 1987 1988 193'3 <br /> A (multiply 1 by fee for <br /> C each year applicable) f <br /> 1 <br /> STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> T t Tanks /_ x $56.00 1986 1987 1988 <br /> i 1939 <br /> Y (enter iouit and year) <br /> �Q $ <br /> L PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 6 CLOSURE FEE _ $90.00 each TANK t Tanks_____ x $90.00 $ <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK t Tanks x $80.00 S <br /> L PLAN CHECK (Installation or Repair) <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> R REPAIR <br /> EE TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x $110.00 i <br /> A -- - <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr b <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> ESWEEPS COMP Y LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED <br />