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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> AACILITY/SITE NAME r FACILITY C TACT NAME <br /> I STREET ADDRESS l / 4 y SITE PHONE # WITH AREA COOK <br /> Y CITY STArE XIP CODE - $ of Tanks <br /> // � � at Site L k— � IJ <br /> A APPLICANT/BIL ING NAME r r APPLICANT CONTACT NAME <br /> P y ` <br /> L _—_- <br /> I MAILINfi AODRES / APPLICANT PHONE 0 WITH AREA CODE <br /> N CITY ^7— TATE 1IP'CODE TYPE of APPLICATION <br /> T ,� ,.fl _ - -J. ;, '�, CLOSURE, INSTALLATION, ETC. Q_ <br /> FACILITY FEE _ $100,00 each SITE ADDRESS per YEAR -- TOTAL <br /> A --- - -- - ---------- <br /> T 1986 1987 1988 1989 <br /> 1 S <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F $ Tanks x $50.00 1986 1987 1988 T-1989 <br /> A (sultipry-i by fee for <br /> C each year applicable) f <br /> 1 <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> T I Tanks x $56,00 191 1987 1988 1983 <br /> Y (enter iiouot and year) --- — — <br /> C PERMANENT CLOSUR (Remova or Closure in-place) <br /> $ <br /> 0 CLOSURE FEE = $90,00 each TANK 1 Tank— ss x $90.00 f <br /> S <br /> U.. <br /> R TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> E --------- - <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK $ Tanks x $80,00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L -- RECEIVED <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUONISSION f <br /> REPAIR <br /> R TANK REPAIR FEE _ $110,00 each TANK rq It EAkTh.DO $ <br /> E — <br /> P — — -------_ _---- - <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimus one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00lhr FEE _ $35.00/hr — FEE_= $35,00/hr f <br /> TOTAL DUE f Ooo <br /> OFFICE USE ONLY pQ J 1 <br /> DEEP 1 COMP f� LSO ODE DIS �'I�ilEI�IVI„Gf AMOUNT DUE <br /> 1E R1 Va tI�MIVRVe�7ICH-EfJ�lq' If ASII U fiQl PufiTl .G�I?IIldl�dRllf <br /> P I II It,� l <br /> RCVD BY DATE RECEIVED PEPAIT t <br /> .. . ._._.._ . ---- <br /> 05 1e�o2u (j�} 32�... .. GOA` 98 -t� <br /> 5 &"I I�IB9 9G �19�1` ,fl! P I 11191111 111 A@Bff9�ll ll�ll�,��'J ! If�911 ID�Ilffffaf4. �Pf Ei 9 k <br /> ,., I _. <br />