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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> 7�, <br /> ------- <br /> e <br /> 1 � SITE PHONE "ITK AREA CODE <br /> L STREET ADDRESS G <br /> 1 3 iT ?0. 7 - .3 y5 <br /> I ST T ZIP CODE 1 of anks <br /> Y CIfY I 1 1 530/ at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L "'-'-- ~ APPLICAN PHONE 1 "IT" AREA CEOE <br /> I MAILING ADORES <br /> A STAT 11P'COOELI.APPLICATION <br /> N CITY ctOsu"e, I"ETALLATID". ETC. <br /> T— tS�s em- ----.._ C-W X15 I <br /> - -- ---._-- - .... TOTAL <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR ----- <br /> A - - 1986 1987 1989 1989 <br /> C _ — <br /> I PA MENT <br /> I <br /> V — --- RECEIVED <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks -' x 150.00 I---- <br /> 1986 1381 - 1988 19A (multiply-I-by lee for SA ALTH SERVIC <br /> C each year applicable) -_ - WL <br /> STATE SURCHARGE _ 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 2528 �1{� cya�llicYr <br /> I 1 Tanks x 156.00 1986 - 1987 1988 1983 - _- <br /> Y (enter aiount and year) 1 <br /> C PERMANENT CLOSURE mO+ova wr Closure-in-place)_ a�j( c �,�;t' el �; - - <br /> --- 1 Tanks__ _ x (30.00 f ' NC;sU <br /> 0 CLOSURE FEE : 190.00 each TANK --- - <br /> SR.. --__ ----- <br /> U ------_-..-_- _ ---- -- <br /> TEMPORARY CLOSURE (Only allowed one time for up to two years) Tank <br /> E ----- - -- - - <br /> 1 Tanksz (80.00 <br /> TEMPORARY CLOSURE FEE 2 $90.00 each TANK - - -._-.--__---------- <br /> -------- ---- <br /> P PLAN CHECK (Installation or Repair) -- -- - - <br /> L ------ - --- -- f <br /> A <br /> N PLAN CHECK FEE _$30.0--0 each SUBMISSION/RESUDMISS <br /> REPAIRx $110.00 1 <br /> 1 Tanks_ _ <br /> R TANK REPAIR FEE = 1110.00 each TANK - <br /> E- --- <br /> p ....._-'-- ...._.._...- -- .- -. <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal <br /> - -' - -- SAMPLING IIISPECTION <br /> I .UNAUT UNAUTHORIZED E (when applicable) <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION <br /> applicable) <br /> (when applicable) 1 <br /> FEE _ 135.001hr <br /> FEE : 135.00lhr _ <br /> FEE = 130.00IhT -- - <br /> _..._. ---..__--------- TOTAL DUE f `� O OU <br /> OFFICE USE ONIF <br /> 1mF�!��.V°@INN INN1flNmINIINIPV.!V.NN9f' ,i <br /> 11011 IONIAN' "NRVdf:T�lllI�NGIININ�111BININII!IfniN.IIINN9':',iGiNIiNNfiV, iIkAVVCVNfNNNRNfNNINNIO NNGI4@VI�N9��+� u <br /> I�NNAINN NNN9N IANIAflNIflAINNNANNPNuNN�I. A�NN�NN��I!T 1 f' <br /> ...... INfANINNAIn iN�fIVQ Y DATE P,ECEI�ED <br /> ,WEEPS 1 I COMP 1 LO( CODE DIST ICODE <br /> III AMOUNT OU�NI;NNI�NI�pANIINNNVNI�NNNN:Af�NNfNNIIINNAIIN�INNECK 1/CASH RPVD _ <br /> 'Mh�r'�ui � �i,.u. u�/ ill NN.N ' �'PPIINNIINNAw`�.NI��NNNINNNA. <br />