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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _-— — RGROUND STORAGE TANK PROGRAM - FEE WORKSHE� <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> Lti �a_ n t �ck�ers v(�1 lir r� <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> I <br /> T-- 160 w <br /> - - <br /> Y CITY r — S TE LIP CODE I of Tanks <br /> 7537G at Site — - <br /> A APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> C !oar <br /> A — <br /> N CITY _ STAT LIP CODE TYPE of APPLICATION sdLm phA <br /> (]��o(o CLOSURE. INSTALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR * l TOTAL <br /> A... --- F__ — - ---- <br /> C 6 1987 1988 1989 <br /> T <br /> I $ <br /> V -- — <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanksx e <br /> (50.00 1986 1987 1988 1989 <br /> A (multiply_r_by fee for <br /> C each year applicable) f <br /> I --- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 4 SAFETY CODE Sec 15287 for applicability) <br /> T I Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter 5656t and year) - I - - <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> D CLOSURE FEE = $90.00 each TANK f Tanksx $90.00 f <br /> S--- <br /> U--- --- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK ---- I Tanks______ x $80.00-- f <br /> P PLAN CHECK (Installation or Repair) <br /> L -- ----- - - --- <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR ------ --- <br /> ------- — -- <br /> R TANK REPAIR FEE = $110.00 each TANK I Tanksx (110.00 f <br /> E---- -- ----- ----- - - -- ---- ------- - <br /> P — — <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/hr FEE _ (35.00/hr - S ) �' $ ? c>a <br /> TOTAL DUE Is rra <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT <br /> z @B <br /> MUM c7 y�IMinn= RUIUMMINMI101 Ellin=11M MUMMM liffiliffifflimm] <br /> "-LO <br /> R"INUMNINEN <br />