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SAI1—JOAQUIN LOCAL HEALTH D',...JTRICT <br /> UNDERGROUND STORAGE TANK PR06RAM - FEE WORKSHEET <br /> A <br /> FACILITY/SITE NAME — — — �— FACILITY CONTACTONAME <br /> C L <br /> I — <br /> L STREET ADDRESS SITE PHONE t WITH AREA CODE <br /> Y CIiY -- 15TAT IIP CODE t of Tanks -- -- <br /> Y7�� at Site <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L ---- ---—.__..._— <br /> I MAILING ADDRESS APPLICANT PHONE t WITH AREA CODE <br /> rr <br /> N CITY — --� STATt]'�-- IIP CODE TYPE of APPLICATION <br /> T - - -- --�1 - CLOSURE. INSTALLATION• ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR — — TOTAL <br /> T 1986 1987 1988 1989 — <br /> I f <br /> V —��_.-_.___ <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks _ _ x $50.00 1986 1987 — 1988 — 1989 <br /> A (%itipiy-f by fee for <br /> Teach year applicable) _ $ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH It SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter NiHt and year) <br /> L PERMANENT CLOSURE (Removal or Closure-in-place) <br /> --- -- <br /> 0 CLOSURE FEE _ $90.00 each TANK i t Tanks_ z (90.00 <br /> S- <br /> U ...— <br /> E TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> - TEMPORARY CLOSURE FEE _ $80.00 each TANK ~ rt Tanks _ x $80.00 -- f <br /> P PLAN CHECK (Installation or Repair) ----- <br /> L - ----- -- -- ---- --__— <br /> A - - <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSIONAESUBMISSION <br /> REPAIR <br /> P. TANK REPAIR FEE = 1110.00 each TANK t Tanks x $110.00 f <br /> F <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.00/hr FEE _ $35.00/hrFEE = 135.00/hr <br /> TOTAL DUE $ o0 <br /> OFFICE USE ONLY <br /> N 111111IGGTMGGIIGGIGG1G!IG9tGNImN1GCV! 9'19pG9Gi GuGfi1GIGGIGftii9liVGG!IGI?GiIGiG19!1III'GIGIGVGGIG!WN;IV1IiIGI"!GIB!Ra1fGJI�IpiG!IIiGGiIIiBIGl11!uiGl!IIIIII'"iGuTIiGGIi.fGGGII1G89RV!�GGiIG�If��IW <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I CASH RCVD BY DATE RECEIVED PERMIT t <br /> _....__-.'�IIF��!GI:!GIGGGI�000G•.!GG �— �GGGG�G�I�G GGII IIGGGoIGG91 <br /> GIGGGGGGI'f! i .GIGIGG!IGI@LIG iG.'•!IGGGIIIG�'iGGGII000GGG� �Ua GCGGIG. �GIIIIIG�IGG111GGRIIGINI�000GGIGIt <br />