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SAN JOAQUIN LOCAL HEALTH DISTRICT t,a0 <br /> GROUND STORAGE TANK PROGRAM - FEE RORKSHEE - �Tfl / 50 9kc <br /> ,AF FACILITY/SITE NAME FACILITY CONT 7i NAME <br /> I / ( de ;- Iq aln, M'^0 e <br /> T STREET ADDRESS E. <br /> t SITE PHONE f�'�" AREA eoo9 13 <br /> Y <br /> Y CITYSTATE ZIP CODE t of Tanks <br /> —'!' Les C� at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P K1er w ( ev� <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE t "'r" AREA coo, <br /> C 8' S <br /> N CITY (� TAi ZIP CODE APPLICATION <br /> T U'�Ci �, J� ,.omuR,. �R,rAUAr,OR. etc. <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 1986 1987 1988 1989 <br /> V — /oo oo ' $ 3oo <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks _ _ z $50.00 1986 1981 1988 1989 <br /> A (AultipIy I by fee for <br /> I each year applicable) $ S D O $ s(7 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter anount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L O <br /> 0 CLOSURE FEE = $90.00 each TANK f Tanks ( x $90.00 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK $ 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 f <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK f Tanks z $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 /> I <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 <br /> 1/a3�89 TOTAL DUE f <br /> OFFICE USE ONLY poQ 64th '` !35 f <br /> SWEEPS I COMP f LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO CHECK t/CASH RCVO BY DATE RECEIVED PERMIT $ <br /> �L — / 404/36t/3 <br /> liu i i i N <br />