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SAG,- JOAQUIN LOCAL HEALTH D TRICT
<br /> •� UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET
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<br /> _.-.-...____... _..._____.._.__..._..._..._._...._._._._____�._____..._... _ --------..._.
<br /> (NIfACILITY/SITE NAME wwII p rFACILITY CONTACT NAME
<br /> r: S 1 UCc lulu ICrcc,(J n II �t�kLrd Zu L-y PL-Z-
<br /> L STREET ADDRESS SITE PHONE # wITH AREA CODE
<br /> Y CITY STATEII IIP CODE # of lanky
<br /> ....�...._I.�_C I TQl1�...__.---..__....._._.._.___.._...._.__._.__._L _.1.__ Sa 0 _.._._at Site D1� .___._���---_-.__._.__.—___..-•
<br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME
<br /> P _ _
<br /> AI-0 Lis
<br /> L............_........._._.........
<br /> I MAILING ADDRESS APPLICANT PHONE # NITH AREA CODE
<br /> A....._..._...
<br /> _ .`..._....... ..:........._ 10_L,N_L ._..._ .--AOL_.. - _..._..__._......__...... _. ..
<br /> ST TE ZIP CODE A
<br /> , CITY A
<br /> 1 �'].��/.'..� CLOSURE NBTALLAT 10 ------ --
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<br /> . ---_-----.-._.-.__._�_ r..._._�..__._.....--.-•-1G.._-..._.......... _-- ---- -----
<br /> FACILITY FEE - $100.00 each SITE ADDRESS per YEAR TOTAL
<br /> A ..............._...._......_........................._......_....._...--.---•-•---......__.._..._................................................................_............
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<br /> i_: 1986 1987 1988 1989
<br /> 1 _....._._..___.___.__......_..._.._....__..__._........._...__.___._..__......_..__._.._..._._.__.[�,.....____-..____._._........_..___...........__.....---_...___..__.........._..........____.--.---. _ __._ _. ___—___ __... _.__._
<br /> E TANK FEE _ $50.00 each TANK
<br /> . __ __ __ __ __._..-- -_...... . .
<br /> F # Tanks x $50.00 1986 1987 1988 1989
<br /> A (mu 1 t i p TyTb y (ee for ......-......_...___.._...__........._.._...__._..___....._.__........_._._._......_........__..._...._....__..._....___..._-.--•--__ .____ _.___ -._-_--____--..___
<br /> each year applicable) so f ��
<br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability)
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<br /> T I Tanks x $56.00 1986 1987 1988 1989
<br /> Y (enter am-ount and year) ________._._..___..._......_._.__.____.._...._.___-----_-----_.._ -.__--_._...__.._.._.-.._.__.---_--_....____-- --_.__-•-
<br /> ...................._.....-..........___..� ..........._--_-_._..
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<br /> C PERMANENT CLOSURE (Removal or Closure-in-place)
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<br /> 0 CLOSURE FEE = $90.00 each TANK I Tanks I x $90.00 f
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<br /> U ..._......... ...................._...._._.............___..__-----•--_....._-._._----
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<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 /> 1 ......_.__..__...._............................_..._...__.............__..._.__.._.__.._._..__..._.__.____._...___._.____ .___I. _._. ....-.-.--.-..-..____....__.--...._......_._....__.__
<br /> P PLAN CHECK (Installation or Repair) ----
<br /> L.-._.... _ ................................._..__..._._............--....- _._......._.. - ..._.....- - ....-- --._.._.._._..._.....__........_.._....._-....._.- _._.._..__._.._...._._.__....._.__.... ----
<br /> IN PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION $ _30 —
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<br /> r.._......_..._._._...__..._.._ ....._...__._.___......_..._ ..._.____..._._._...__..__....__._..__..._ .__....._....___. __..._...___..___.__._.__..___.____..____.___....._____
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<br /> REPAIR
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<br /> _______._.._,.---_.__._._._...._...__....-•------•--____-_ ._.__._._.._....--__-_..
<br /> R TANK REPAIR FEE = $110.00 each TANK �# Tanks x $110.00 $
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<br /> E_............__..._..._...-..............I...........................- ._..._ __ __._._._._... .................................._........._..............................................__.............._..........-..._..._....._._.__...................._.._..............r _-- - -
<br /> P....................._._...__..._...._..............._._......_....._._.-..._..__...._...__.------._-..._...........
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<br /> A PIPING REPAIR,/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal)
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<br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING 111SPECTION
<br /> (when applicable) (when applicable) (when applicable)
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<br /> FEE _ $30.00/1ir FEE _ $35.00/hr FEE = $35 00/hr $
<br /> _._._...._.....__......... _ _..__.._...._..__....._...I......- -.._...__...._......_._.................._._._......_:....-._...I....._..........__..._.-._____..._..__.......
<br /> __...__.._
<br /> TOTAL DUE f a a CQ `-
<br /> OFFICE USE ONLY T
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<br /> II SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVDCHECK /CASH RCVD BY DATE RECEIVED PERMIT I
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