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SAN JOAQUIN LOCAL HEALTH DIS'i .,ICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> IA <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> L STREET ADDRESS WE PH # WITH AREA CODE <br /> T <br /> Y CITY2A VZIP'L'ODE # of Tanks <br /> 15/1-6-7 lat Site �� <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P 7aZ'/D kz e;�' <br /> L <br /> I MAILING ADDRESS LICAK PHONE I WITH AREA CODE <br /> N CITY CODE 0 LIGATION <br /> T CLOSURE, STALLATION, ETC. <br /> FACILITY FEE $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T <br /> E TANK FEE = $50.00 each TANK <br /> I ............. <br /> F I Tanks _ x $50.00 1986 1987 1988 1989 <br /> A (multipTyby fee for <br /> C each year applicable) <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter ii-06ht and year) — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK =Tanks------ x $0J0,00 <br /> S.... <br /> U <br /> 11TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks_ x $80.00 <br /> ........................... ........ <br /> P PLAN CHECK (Installation or Repair) <br /> L--------- <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R TANK REPAIR FEE = $110,00 each TANK I Tanks x $110.00 <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 EVALUATIONSTR <br /> . (when <br /> CONUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (w I applicable) (when applicable) <br /> E <br /> FEE = $i­00;­ $3 5.00/hy FEE $35.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> 011!11118321115 1 I'm,11011-11211iii 11191 9.oil 1911.1 <br /> MI: <br /> I-M-111.1 11111 win 111111MI.M.M.111111111011 a 110 1 M.M MIT'll 01.1911,11111 US 111 "M IN 11 ii,11111111 MEN1111"A'S WER <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD ASH RCVD BY DATE RECEIVED PERMIT I <br /> ................................... .......... ...............-............... ............- ... <br /> i, IL <br /> VAZ <br /> ills m!I11mi <br /> 'Im M11111111110011111 Ili IN( MIMM Ll [11111 <br />