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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PRORRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> 'C I/a c z� b ye <br /> L STREET ADORE n ' SITE PHONE ! WITH AREA eooc <br /> I '✓ <br /> T <br /> Y CITY / _ / TA Z[P CODE t of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> R <br /> Clu//w6aL /ti <br /> I MAILING ADDRESS APPLICANT PHONE ! WITH AREA CODE <br /> C S G s tTYFP <br /> oq 33 <br /> N CITY ///�� n STAT ZIP CODE of APPLICATION <br /> T-- tq C r URE. INETALLATxON.�TCD� <br /> FACILITY FEE _ $100.100 each SITE ADDRESS per YEAR TOTAL <br /> A — — — <br /> T 1986 1987 1988 1989 <br /> /L-)C)— <br /> TANK FEE _ $50.00 each TANK <br /> F ! Tanks x $50.00 R5��Io- <br /> 86 1987 1988 1989 <br /> A (multiply-I by fee far <br /> 1 each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> I — <br /> T ! Tanks x (56.00 1986 1987 1988 19119 <br /> Y (enter a-miuot and year) <br /> lv $ 56 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> O CLOSURE FEE _ $90.00 each TANK <br /> S ! Tanks x $90.00 f D <br /> U <br /> R TEMPORARY <br /> E CLOSURE (Only allowed one time for up to two years) <br /> — <br /> TEMPORARY CLOSURE FEE = $00.00 each TANK ! Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L — <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK ! Tanks x $110.00 f <br /> P <br /> I 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 INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr f <br /> -- TOTAL DUE $ <br /> OFFICE USE ONIy c tys <br /> SWEEPS ! COMP ! LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK !/CASH RCVD BY DATE RECEIVED PERMIT t <br />