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SAN JOAQL I LOCAL HEALTH DISTRIC <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME — FACILITY CONTACT NAME <br /> ockt�� �� Lnr tstf IE, Frticl ltie_.lIS <br /> I <br /> ITREETA� SITE PHONE 11Trm � soK <br /> I 1 lLtnC `scN� �� (a.n9) —/Y8-91DI <br /> Y CITY �fo� ;j T qlip C DE s� � s 1 0l Tanks <br /> l ll_�Gt +t Site <br /> A APPIICANTl11lLING NAME APPLICANT CONTACT NAME <br /> P <br /> L -- — — <br /> 1 NAILIIN ADDRESS APPLICANT PHONE I YIT" mm <br /> Co <br /> 5 . P (�1� (a.oq) Lt(0a- 99 It <br /> N CITYAi IIP CODE LOe�e A;PLICATION ra <br /> T 2h 1 7M 1 L ;a0to <br /> FACILITY FEE ■ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 1986 1387 — 1988 89 <br /> 15lo� � <br /> E TANK FEE • 150.00 each TANK i OEC <br /> F1 Tanks - 1 150.00 1986 - —1381 1988 — _ 1909 <br /> A (wltiPly'I_by lee for -- <br /> C <br /> o k year applicable) `, �' f I u G <br /> ITATE SURCHARGE ■ $56.00 oath TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for p I-ta 1 <br /> T 1 Tanks----, 1 156.00 1986 - 1987 - 198 -- 1383 <br /> Y later amount aM year) --- <br /> t <br /> lRNAM <br /> PEEAT CLOSURE (Removal or Closure-in-place) <br /> 6 CLOSURE FEE ■ 190.00 each TANK 1 tanks s 130.00 1 <br /> U . — ---- <br /> I TEMPORARY CLOSURE (only allowed one time for up to two years) <br /> E TEMPORARY CLOSURE FEE • 180.00 each TANK 1 Tanks 1 180.00 S <br /> P PLAN CHECK (Installation or Repair) —-- <br /> L - -- ---_— <br /> A <br /> N PIAN CHECK FEE 630.00 each SUIMISSION/RESUCMISS1011 f <br /> REPAIR -- - ---1— <br /> R TAW REPAIR FEE • $110.00 tick TANK1 Tanks r $110.00 f <br /> E <br /> 1 PIPING REPAIR/CLOSIIRE/REMOVAL (fees are per hour, minimum one hour to be paid on plan submittal) <br /> IT UNAUTHORIZED RELEASE EVALUATION JCONSTRUCTIOM INSPECTION SAMPLING INSPECTION <br /> Whom applicable) (when applicable) (when applicable) <br /> FEE • 130.001kr FEE • $35.001hr� FEE _ $35.00/hr, t <br /> TOTAL DUE f <br /> DFFICE ISI DAY <br /> SYEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVOHEi;3/CASH RCVD DY DATE RECEIVED PERMIT 1 <br />