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�! SAN*-JOAQUIN LOCAL HEALTH DISFRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> (F FACILI / ITE NAME FACILITY CONTACT NAME <br /> 1 A L � 1 <br /> C J V'a QV lJ <br /> 1 <br /> L STREET ADDRESS SITE PHONE t "T" AREA caoE <br /> 51 5 7 A. S. <br /> Y CITY ,n ATE IIP CODE t of Tanks <br /> "I � at Site (O <br /> A APPLICANT/BILLIN6 NAME A ICANT CONTACT NAME <br /> I MAILING ADDRESS APPLICANT PHONE 1 NITN AREA cone <br /> 3 , 1a� _ _ __ og -5a - 6 5 3 <br /> T CITY TATE]IZIP•CODE TYPE of APPLICATION <br /> f� ✓� � i!�,I cL.asuRE. INETALtATIOR, era <br /> FACILITY FEE z $100.00 each SITE ADDRESS per YEAR - - — VVV-,TOOT000ALL <br /> A...__--_ E01 <br /> __ —C 9861967 1988v 0 00 O U - SOC) — f O U <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks y x $50.01) 1986 1987 1988 1989 <br /> A Imultipfy 1 by lee for <br /> C each year applicable) 30 O 300 30 O 30 U 1 0 U <br /> I ---- <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> I -- - -- <br /> T 1 Tanks x 156.00 1986 1987 1988 1989 <br /> Y (enter iiouit and year) --- -- -- -- - - - -- - <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) --- — <br /> L - --..—_ - --- --Is <br /> — <br /> S Tanks__-E <br /> CLOSURE FEE _ $90.00 each TANK -� t 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 TANY, ---- (-t Tanks_ x 180.00 -- Is <br /> P PLAN CHECK (Installation or Repair) -- — - ^— <br /> L -- _.._ ... _ - .-..._.__......._.. <br /> A <br /> H PLAN CHECK FEE = 130.00 each SUBMISSION/RESUDMISSIOII f <br /> -- <br /> REPAIR ---- --------- ---- - - <br /> �__—___� <br /> R TANK REPAIR FEE = 1110.00 each TANK t Tanks - x 1110.00 _ f <br /> -- <br /> P ----_.-_... — -- --- - <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> t _�--- --- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $3O.00/hrL— 35.00 <br /> — FEE = 1 /hrL�- - FEE _ $35_00/hr - <br /> TOTAL DUE 5 �� - <br /> OFFICE USE ONLY <br /> SIC'1! m.V"19�mm691m111>mlull�iml ImPI m1R9, J1�ll!I! Im 1m1A2mauiiPIIIR"1CmV 1N9illmmlllm"!1m11V19'JG1fu�411�f�mllpm�?11!mmmIIGI�T1 i11m 1!IIii1111V1r1!,:GTlifi'Im0ni12011111 lmlmmmllm11PJ!!5111!11111!mJii1P"1 <br /> ;U'E�3L MlCOMP I�ltasr LOC CODE DIST CODE AMOUNT E 22AMOUN96fVD -CH3E� ASH I R�,,D�r�/DY DATE RECEIVED PERMIT t pI� <br /> m. 1M111111!4i�111m11 111m11. •. 1!11m1m1mm!mmm!11... 111m1@1111m1711111 ml�1&!U N M118 11!GGGG� <br /> m11V..I�...IC�llml!111mmm.,�.NIN.11111,���1mam, m1� <br />