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SAN OAQUIN LOCAL HEALTH DIAICT <br />D <br />UNDERGROUND STORAGE TANK PROGRAM - <br />_FEE WORKSHEET �O <br />F FACILITY/SITE-NAME _ - --�- - FACILITY CONTACT NAME <br />r M 0 FSA M sit e D A. TA APs <br />I --- <br />STREET AODRES SITE PHONE 1 WITH ARRA CODR <br />16P1 {--(AIM M t: CL l N'E- 20 q -47 S -2725 <br />Y CITY STATE YIP CODE 1 of Tanks <br />TV <br />a�SZp at Site fiOUjZ C4) <br />A APPLICANT/BILLING NAM APPLICANT CONTACT NAME <br />P <br />1 f�1I S Ela _ --- _ <br />�(LL MF�1z-(L_UGf-1 <br />1 MAILING ADDRESS ` APPLICANT PHONE t "IT" AREA coo! <br />C ��? .T�-o5�_v�[.L (2oA� lu(TG-_I®3_ <br />N CITY �- _-,�-- S/T'ATE /jitP'COOE tYPE of APPLICATION <br />-- N �� _ S� c. Pa) v�(�a1 C/^� Il CIOeVRCr INSTALLATION, ITC. INCA /1 / 7oA I <br />A FACILITY FEE = $100.00 each SITE ApDRESS per YEAR, -- <br />TOTAL <br />C 1386 1981 1388 1989 <br />T 12t;pUWCC'MEtiTjr7 <br />E TANK FEE = I50.00 each TANK <br />F 1 Tanks �- 150 <br />A .00 <br />A (multipTy-i-by fee for <br />C each year applicable) <br />1986 <br />1381 1988 <br />1389 <br />Ia a <br />�O, <br />_ <br />L STATE SURCHARGE _ $56.00 each TANK (see CA H <br />LTH It SAFETY CODE Sec 25281 <br />for applicability) <br />T 1 Tanks 4 x 156.00 <br />Y (enter aiount and year) <br />1986 <br />.. <br />13 81 <br />�� <br />C PERMANENT CLOSURE (Removal or Closure -in-place)— <br />0 CLOSURE FEE = 190.00 each TANK <br />U <br />P. TEMPORARY - CLOSURE (Only alloyed one time for up to Ivo years) <br />E----- a-----------------__.._ <br />TEMPORARY CLOSURE FEE = I80.00 each TANK <br />P PLAN CHECK (Installation or Repair) <br />I Tanksx 130.00 <br />ll Tanksx 190.00 <br />A----------------- <br />II PLAN CHECK FEE = 130.00 each SUBMISSION/RESUCMISSION FA(D W I TlfFAE - < Pr <br />AA"AL PEJZWl ( T- <br />E TRRNS_C-� <br />. .REPAIR <br />P TANK REPAIR FEE = 1110.00 each TANK--- �- �— <br />1 Tanks <br />x $I�I0.00 <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan ubmittal) <br />R UNAUTHORIIEO RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IfISPEr,T10N <br />(vhen applicable) (vhen applicable) <br />When applicable) <br />FEE _ $30.00/hr FEE _ 135.00/hr FEE <br />2 $ <br />TOTAL DUE <br />I <br />OFFICE Os( ONLY <br />SEE <br />SWEEPS 1 I_ _COMP t .ILOC COOEIDIST CODEI AMOUIII DUE.I AMOUNT REVD I CHECK i/CASH I RCVD BY I DATE P,ECEtVEtlI PERMIT f <br />