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SteJOAQUIN LOCAL HEALTH *STRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> -..._....._........_......___._..------_...._....__-------.—. FACILITY CONTACT NAME <br /> F FACILITY/SITE NAME <br /> I - SITE P.HONE`I 'T" AREA coca <br /> STREET ADDRESS Cv � - FAVMMNT <br /> — <br /> TCODE I of Tanks RECEIVED <br /> Y CITY at Site <br /> --'-- -C '--- APPLICANT CONTACT NAME JINN <br /> A APPLICANTFBILLING NAME <br /> F' <br /> L ----- 6 r/G -"--'�—y APPLICANT PHONE i "'T" MM"f SERVICEr <br /> I MAILING ADDRESS „ <br /> M rl1Y STAT IIP CODE TYoeuRi,A1"ST�A��TNoN, ere. <br /> - -- <br /> _..._....... ---- -- - TOTAL <br /> FACILITY FEE = s100.00 each SITE ADDRESS per YEAR _,____.. ___.-_----------------- -'"'"-- " <br /> A ..._...._____..__.._._...__—. 1386 1387 1388 1383 <br /> ----- <br /> T — s o <br /> E TANK FEE = 150.00 each TANK _ <br /> F 1 Tanks f_ z 450.00 1986 1381 1988 1983 <br /> A (evItiDTy 1 by tee for <br /> r. each year applicable) > J �_-.-- -- <br /> 1 -'-- — "--'-� applicability) <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for _ <br /> T 1 Tanks I x 156.00 1306 1987 1388 1383 <br /> Y (enter asount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) _ -- <br /> 0 CLOSURE FEE = 130,00 each TANK T1 Tanks z 130.00 1 -_ <br /> U -------..—__.._...._ --.— <br /> F. TEMPORARY CLOSURE (Only alloyed one time for up to two years) ---- -- <br /> E -------------------•-----•---•— 1 Tanks <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK x 180.00 1--____-- -- <br /> PPLAN CHECK (Installation or Repair) <br /> L <br /> A 1 <br /> II FLAN CHECK FEE 130.00 each SUBMISSION/RESUBMISSION <br /> - - -_ —, <br /> REPAIR <br /> F. TANK. REPAIR FEE = 1110.00 each TANK 1 Tanksx (110.00 f <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R (whenUNAUTHORIZED pplic RELEble) SE EVALUATION CONSTRUCTION <br /> applicable) <br /> INSPble) TION SAMPL(when <br /> INSPECTION <br /> liable) <br /> (when applicable) (when aPDlicable) (vhen applicable) — _---_-------- <br /> ---- _._......-...._... -- --..._...._-- --'-------- __ <br /> FEE = 130.00/hr� FEE = 635.00/hrI FEE = 135,00/hT 1 <br /> __._.... --..._..-._.. <br /> TOTAL DUE f pp <br /> OFFICE USE ONIy <br /> lu <br /> ;WEEPS 1 COMP 1 LOC CODE DISI r,ODE AMOUNT OUE AMOUNT RCVO CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> ��. fl4!IINV�Nfifl�l pflpPlli ISI I�Imllll�'P:�I�1 i, �f�I� IIflIIC oc <br /> 1 I. pfl gl�fl Il�l�l lliflfllfll �lfl.. �1 11�4�@RII91 III VIII <br /> ESI <br />