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JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />' �F FACILITY/SITE _ - ^� <br /> A — FACILIFY CONTACT NAME <br /> I € t _ <br /> j i _--��� �- L L�L l�'f�c! X1 <br /> ' Z 0 Z^pL- Cl [?. C.... <br /> L STRUT ADDRESS _ <br /> I 1 - '7 SITE PHONE I u.THT, <br /> ARIA rtroe —I <br /> YCITY STATE IIP CODE I of Tanks _ <br /> -+ 1 at Site <br /> j e <br /> IA APPLICANT/$ILL IN6 NAME `- ---- '- ----- -- - -_ <br /> P APPLICANT CONTACT NAME <br /> d MAILING ABODES5 <br /> e APPLICANT PHONE 1 w-r" ARew cone <br /> A' CITY --- <br /> T� NATE IP CODE TYPE of APPLICATION <br /> -- C�OSVRF- IN�TAlLAT14N- ETC. <br /> FACILITY FEE --5100.00 each SITE AD PE ���� <br /> A `___._�� _ DESS per YEAR ------ --- _ TOTAL <br /> 4Ob° 1937 ----- — <br /> T 1_ !988 1909 <br /> E TANI, FEE - <br /> ; 00 <br /> 50 aach TATtK <br /> F f Tanksx 150.00 1906 190/ <br /> IA (mul.,pfy"f_by fee for <br /> �+, each year dppl,kablel <br /> L STATE SURCHARbE = 156 00 each TANK (see CA HEALTH 6 SAFE 5 7 for <br /> _ __ TY Cupc SEC 2a[8, �u. apltli�abil�ty) <br /> �Till Tanks -~ x 156 c�0 �- , 1386 _ E981 r <br /> Y (enter aiount and year) __.._� <br /> +: PCP,M/,TIENT CiOSIlPi (P,enoval or +;i. � -pla, e)in <br /> CLOSUPE FEC - v)0,00 each TANK _ I Tanks <br /> _�....__. <br /> P TEMPOPARY CLOSURE (Only alloyed one time <br /> for up to No years) <br /> IEMPORARY CLOSUFC FEE - f `� `�—"----- ---- <br /> _ 80.00 each TANY, --1 Tanks_ <br /> PLAN CHECK (installation or Repair) <br /> �If PLAN CHECK FEE = 130,00 each SUBMIS51OH/fiESUCMfSSIOTI <br /> F TAN). PEPAIR EF; (110.00 eaf h TANK - <br /> E 4110.00 1 <br /> A PIPING REPAIP/CLOSUPE/PEMOVAL (Fees are aer hour, ainiau,i� �- - --` <br /> i ------ �_ � .,_—,_—_ ' Dile hour to be paid or plan submittal) <br /> R UNAUIHORIIED PELEASE EVALUATION CONSTRUCTfON INSPECTION-` <br /> (when applirable) ry _ (Oben UC ION INS) SAMPLING 1IISPECTION <br /> When appli(able) I <br /> FEE - f30.001hrL T - --- -- - ---T - --- --__ ___ __- --- - --- <br /> �_____ FEE = $35 00/hrt <br /> TOTAL OLE - <br /> OFftCf O5E QRt)' <br /> , „ 1MRI1100 IfR�Rli 1" x <br /> rSWFEPS I COMP I LOC CODEDIST CODE AMOUNT OUE A MOUNT C <br /> _ - T-.-w - RVL+ LHCr,K I/CASH FCVD DY j RATE PECFiVEO PEPMIT 1 <br /> RONNIE <br />