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SAJOAQU I N LOCAL HEALTH ` <br /> DISTRICT `�.f <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACIL�,t1Yf51TE NAME <br /> FAC[LITY CONTACT NAME <br /> } j }-1Li11 C l (- <br /> L STREET ADDRESS SITE PHONE WIT" AREA Cob[ <br /> Y Cl /STATE .ZIP CODE I of Tanks <br /> �?`► IOU at Site <br /> A APPL[CANTfBIIL[NG NAME <br /> P APPLICANT CONTACT HAMS <br /> I MAILIN DDRESS <br /> �- APPLiCAN PONE f wirN AREA coo[ <br /> N CIT j`.� <br /> ��__j� f(� T. TE ZIP CODE T APPLICATION <br /> r_'"•---+-�- �' __.�____.. .�, j 106UR IN�TALI.AT[pNg [TC. <br /> FACILITY FEE --1100.04 each SITE ADDRESS per YEAR _Tn ___ .._.__.T� _...__......__ TOTAL <br /> A .___.____.._.__-- -----_.____ _ <br /> C 1986 1981 _ 1989 1989 -- <br /> 1 <br /> E TANK FEE : 150.00 each TARK <br /> F I Tanks ti 150.40--�• --.'W1986 -. .—.--1981 Y 1988 _ 1983 �- <br /> A Imultip(y-i-by tee for <br /> i each year applicable) _ # <br /> L STATE SURCHARGE = 156,00 each TANK (see CA HEALTH 6 SAFETY CODE'Sec 25287 for applicability) <br /> T I Tanks 156,44 (386 — 1981 1988 1984 <br /> Y tenter 3io651: and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L - <br /> 0 CLOSURE FEE 2 130.00 each TANK I Tanks_ x 49 .04 <br /> U � <br /> -- _._�_ _ ._.___ ______ `__ 4 ) U� <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) + { <br /> TEMPORARY CLOSURE FEE - 180,00 each TANK - I Tanks�J__ x 194.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L --- -It PLAN CHECK FEE = $30.00 each SUBMISSICIIIRESUDMISSI011 — 1 <br /> REPAIR <br /> £TANK REPAIR FEE _ 1110,40 each TANK IITTanksx 1110.00 1 <br /> pW:_—___ _- <br /> A PIPING REPAIRfClO5URI/REMOVAL (Fees are per hourf minimum one hour to be paid on plan submittal) <br /> R UNAUIHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) ---_._— _ (when applicable) <br /> When applicable) <br /> FEE - 134.04/hr f FEE - 135.00/hr ,_��--.-- FEE -'iOS.001hr <br /> 1 <br /> OFFICE USE OKI.r TOTAL DUE <br /> SN.EEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNI RCVDCIECK,I CASH RCVD BY DATE RECEIVED PERMIT I <br /> ��V I6 41% � imp <br />