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1 <br /> 1 <br /> SAIRJOAQUIN LOCAL HEALTH ATRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> IF FACILITY/SITE NAME FACILITY CONTACT NAME <br /> IN �p <br /> I �/� t �14(07ei IN <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> T _. . �oO tau/ _ _ - 971=62(2 <br /> Y CITY ST9TEIIP CODEJI of Tanks <br /> n.Q� at Site . <br /> A APPLICANT/BILLING NAME Y~ APPLICANT CONTACT NAME <br /> P <br /> I MAILING ADDRESS - APPLI NT PHONE I NIT" AREA CODE <br /> J. <br /> A 53_ c�AJ t °.�.�L ___ IIG�9 � <br /> N CITY STAT IIP'CODE TYPE of APPLICATION <br /> CLOSURE. INSTALLATION, ETC. T <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A .._.._ ..._..__.__._.. _ _.. _ _........._._. __..___........_.._ _...__...__. ._.__........._._..__ __.______.__.... ___._.__..____..._____._.. <br /> C 1386 1987 1988 1583 <br /> T <br /> I � <br /> E TANK FEE _ $50.00 each TANK �^ <br /> _..__...._._......_...._............_._ .�__ .. . ___.__._____.___..__.._.................... <br /> F I Tanks _ x 150.00 1986 1381 1988 1989 <br /> A (w l t i p fy f by fee for ------ <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x $56.00 1386 1987 1388 1383 <br /> Y (enter iiount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = $30.00 each TANK � � T 1 Tanks_ <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) _ _ - <br /> E TEMPORARY CLOSURE FEE w $80.00 each TANK �rI Tanks-_... + xx1190.00y <br /> P PLAN CHECK (Installationor Repair) _......M__..�..•__,..._.. _.____..._.._ �•������ ""�""""'"'"'_ ..____.__._.._....______ <br /> L <br /> h PLAN CHECK FEE : . 0 each SUBMISSION/RESUDMISSIO)! <br /> P. TANK REPAIR FEE - $110.00 each TANK _� _ y I Tanks x $110.00 f <br /> ------ <br /> ................ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION~ SAMPLING IIISPECTION <br /> (when applicable) (when applicable) (vhen appli(able) <br /> FEE_- 130.00/1►r FEE $3`.00/hr FEE =$35.00/hr $ .._..__ _ <br /> TOTAL DUE $ <br /> OFFICE USE ORLY <br /> 12=11 MINIMUM NOM0111 111911111LILIL N p'TTIT11111011.?!2112114gll!I �!Ulldw'�� i&IIIIG6IPQI�I�i I!II!uIIIIIIV7a!'a!uGlillll�.C!@��unnCV!�iII�iIIiGiiG�IIGI� 1�i�l�i�ligl!�G��I�IGpGU!�' <br /> SWEEPS 1 COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK CASH RCVD BY DATE RECEIVED PERMIT I <br /> _.._... ....... ..... ........ -'� ......_.._...__........._... n_ <br /> N rc<"': `( <�' c'^t J c'�." qtr A% )�7 ��"",�+. f�........ —.. ...__......... .....-^L-/�`' _.._.._.._.............._._..... <br /> f mI'IMF.91, ���iGa!a4�IICN�I!!I��Ilr�l.?'�III�GI�hpG�!I!l�l�J!�IIIG�i!11�11!hf"�C��/!��g119�liII�IG Uil!�IIIIG�G��IIII�II�G�G(IIIILI,III��BIh"IVI!V��ul!►lug 8�1 6111�In�Vlll����911 Jlq!II Ii64�liIdAU�ll1����!p�l�� <br />