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' SAN JOAQLI I N LOCAL HEALTH DIS W CT <br /> AROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITYISITE NAME FACILITY CONTACT NAME <br /> A g-Z e �G� Uls��� MASK � 4� CdL-L4N <br /> I <br /> L STREET ADDRESS SIT PHONEI (with Area Code) <br /> 1 61 s. VJ4LJ--PN waw( UOU 4fo 3 <br /> Y CITY STATE IIP CODE t of TANK'S <br /> e5rlL9 GAS 15 20 4 at site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I MAILING ADDRESS APPLICANT PHONE I (with Area Code) <br /> c 0. X I2�L© 2�`� Cr18 -lq0 <br /> A <br /> N CITY STATE IIP CODE TYPE of APPLICATION C�iI.Q�UCz� <br /> T TULia ICA, qo,227ED I(Cicisure, Installation, etc.) F1,-rmA0eKrF <br /> FACILITY FEE = S100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C I NG 1'387 1388 1 8'3 <br /> T <br /> I � <br /> U <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tantsx $50.00 1586 1987 I'm 193'3 <br /> A (aultipTy_i_by fee for �y <br /> is each year applicable) S f <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK. (see CA HEALTH & SAFETY CODE Sec 25227 for applicability) <br /> I <br /> T I Tants x $56.00 1986 1987 11388 1939 <br /> Y (enter iuuunt and year) <br /> C PERMANENT CLOSURE((Reaova r Closure-in-place) WO VA <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks-'j__- x $90.00 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks--'- x $80.00 $ � <br /> P PLAN CHECK (Installation or Repair) 4 <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSIONAESUBMISSiON $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK I Tants x $110.00 S <br /> P Tanks----- - <br /> A - <br /> I PIPING REPAIRICLOSUREIREMOYAL (Fees are per hour, ainioua one hour to be paid on plan subaittal) <br /> R <br /> UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.001hr FEE = S35.001hr FEE = S3S.001hr S <br /> TOTAL DUE $ "2 70, <br /> -OFFICF.USE OIL?' --- --- ____ --- -- -- - -- - - <br /> SUEEPS t COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK IICASH RCVD BY DATE RECEIVED PERMIT 1 <br /> ry ar.:• .Y.. ..+..i Y•M- eiyi. �..'� a. 4nr. .w•t- .�-w 'wr. H.';.:r.,rtiu.-. �'f•. 'a � - - ' <br /> Lit Ij U.11 I�Ijdu <br /> y <br /> l.t.t.a '�aCt7�?;7�ur�: ,, � -;.., fir. .• ,..i- .. �i .YF�'S .r.. <br />