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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> A ACILITY/SITE NAME FACILITY CONTACT NAME <br /> Dr. eq Yl r Bt), C4 kI <br /> L STREET ADDRESS Qq M SITE PHONE 1 WITH AREA COOS <br /> T-�� <br /> Y CITY S4_0 CeC,- � S1AT ZIP CODE t of Tanks <br /> — ----- C/} 2 at Site — --- <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> --- _ 5 __4 ..________ _ <br /> I MAILING ADDRESS APPLICANT PHONE t WITH AREA CODE <br /> C <br /> N CITY - --- -- STAT TIP CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, ETC ----' <br /> FACILITY FEE $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> T 1986 1987 1988 1989 <br /> I 100 IOU— / 0(,)- 1loo-1 <br /> E TANK FEE = 150.00 each TANK <br /> F t Tanks I _ s $50.00 1986 1987 1988 1989 <br /> A (multiply 1 by fee for --- - - - <br /> C each year applicable) - $ 0 r 0- <br /> 1 - 5 0 $ 0-\60 <br /> ..--- _ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> I - - - <br /> T 1 Tanks x $56,00 1986 1987 1988 1989 <br /> Y (enter iiount and year) - - _ ^--- --- S &- <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) -'- <br /> 8 CLOSURE FEE = 190.00 each TANK -- -- — 1 Tanks x $90.00 f <br /> U ...------- — <br /> P, TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E - -- ---_�-.-- --TEMPORARY CLOSURE CLOSURE FEE = $80.00 each TANK 1 Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L R g-CLU E - <br /> PLAN— -------- — --- - <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION SEP q f <br /> REPAIR ENVIRONMENTAL HEALTH" <br /> JIICES <br /> P. TANK REPAIR FEE _ (110.00 each TANK 1 Tanks i f <br /> E _- -------- ------ _ _ ..-......-- . - -- <br /> F -- -- - --- -� - ---_---.- —.--- -- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I --- --- �- - - - -- --- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.00/hr FEE = 135.00/hr FEE = 135.00/hr f <br /> TOTAL DUE f - <br /> OFFICE USE ONLY <br /> �m�q'Aq�A9AA�.gVgVAAIAqAPII!qVV"i!gM1f�gPgq'Iqq!IVqV1qlV,qqqqq �I!q�q!!!q!IIgVRllugl!Ii�Ilggfi9GVfVIVigmqqq'.".i:�IIgVgVgVVI�!iWlq,Vqqq 'VIWV!?;q'dgl�IgligllqGqilliqlVlaIVIVV!91111's11°„fuiVilillf 'I�iI�IIVggV!�llgillllglfi!qq�IVq VAGI.�!VI!Vgg191gIVIG�qII"algq! <br /> it SWEEPS 1 COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO CHEfK t/CASH I RCVD BY DATE RECEIVED PERMIT t h <br /> � - - — <br /> 5b,� foSb 00 oo l3 �` 9— -8—qq.-- <br /> �wb��i�o! !�i!onrn � �u,�G�r�gi�i ITT'11 V!lggAVl1]TIM, h4�i�lil�II1Ig11II�IAN.�V�I A�IIAII'��I�q�IAI�IIIGI!IV A!IVIIVf�IIA�I'7gll��!�' AAAIfIlA9�VfVgihl�liVfln�lAIIIIIII�AAl17mIIgV�91. '1111!IA9fig1111PIAlIAI�gGIIAVImqlt� <br /> E�'1�"1�� �, ..�.. <br />