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SAh-�JOAQUIN LOCAL HEALTH L,.,;TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> 1 <br /> C� Cc>n <br /> L STREET ADDRESS SITE PHONE 1 NIT" ANSA CODE <br /> TChns .rNSA <br /> Y CITY}rte �� i1P COD t of Tanks <br /> at Site <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Pne <br /> no a r <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 NITN ANCA cone <br /> N CITY STAT TIP'CODE TYPE of APPLICATION <br /> T H is s C CLOOME, INITALLATtON. ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> A <br /> T 1986 1987 -1988 1989 - <br /> I <br /> E TANK FEE'= $50.00 each TANK <br /> F t Tanks _-_ x $50.00 - 1986 1987 1988-- 1989 ) <br /> A Uultipfy I by fee for — T — <br /> C each year applicable) $ <br /> STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x $56.00 PE- <br /> C <br /> Y (enter iiount and year)PERMANENT CLOSUR (Removal r Closure in-place)- -�� ��� <br /> 8 CLOSURE FEE _ $90.0 each TANK 1 Tanks__ � q O-CO <br /> �__ x f30.00 $ <br /> U ...-- <br /> E TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK TI Tanks _x $80.00 1 <br /> P PLAN CHECK (Installation or Repair) - - <br /> L -- --- -- -- - — <br /> A <br /> 11 PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUCMISSIOH $ <br /> .- <br /> REPAIR — <br /> R TANK REPAIR FEE _ $110.00 each TANK �--� t Tanks Tanks x 1110.00 $ <br /> E ._ -_ -----� __- --_ _._.1....-._ . ------ — - -- <br /> F _-- -- -- <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 k <br /> MPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr - E $35.00/hr$ __.-.-_-_.. <br /> TOTAL DUE Is qo .rn <br /> OFFICE USE Oxly <br /> !CC!CIV000CV�RtlNVCCI0z11VIIVV!IqCENT �igIIC4C4if61P!II�IICPrI"ligfl!I'JVICCI1C1�":!�IV!JpCVVCCV!!ICV!VCCCV9'liCuVi9!fIIIC�IGIiGII!!GI!'11i9iCIiIICu"u IIIIV?1"ifufliCll�fV BICC 9CV!C:IEiCCCIfiVIVICIIICIVIVC ICC9iICVIVCIIf iICiIC!CCCII <br /> ,ISWEEPS 1 COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT P.CVO CHECK 1/CASH RCVD DY DATE RECEIVED PEP,M[T t <br /> V9 _...__ _...._. _. ._....— —..._......_.._.. ._........ <br /> �Q);!If1�tl�HIC�19P I�I IryCVJ GJ. V,.�IVViVVV.VVVCN...MCI.C.I VV.JI.,:II!VC mPVV!!VVIIVVCVIC 11�1Gl1i�VCVVIVIVgNVi!C 11 19Pdll!CVVV' IIC�C!VNVIN MI1XTff111Iq�911 I�I�IQIVVVVVIVPVVV49V..m�@�1PGV��dIVIV�VCVVCVmVi <br />