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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F. FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C bo ve T Pr i « Dave P/ tc <br /> I <br /> L STREET ADDRESS _ SITE PHONE t WITH AREA CODE <br /> T _ � ao � �(o5 -3yv5 <br /> Y CITY SC Q / J �Tp ZIP CODE J t of�Tat <br /> ! C at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Pre c is ivx Tid+ sir;,-s <br /> L -- <br /> I MAILING ADDRESS APPLICANT PHONE 1 wcTH •REQ CODE <br /> A <br /> N CITYl/' / // // STAT ZIPODETYPE of APPLICATION <br /> I vq � C? ✓{S� C- / O / CLOSURE. [ TR L�T[ON. ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR l W TOTAL <br /> A — -- <br /> C 1986 1987 1988 1989 <br /> T <br /> I $ <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks x $50.00 1986 1988 1989 <br /> A (multiply_1_by fee for ——— <br /> C each year applicable) 1 <br /> I <br /> L STATE SURCHARGE = (56.00 each TANK (see CA HEALTH d SAFETY CODE Sec 25287 for app ty) <br /> I -- <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L -- <br /> 0 CLOSURE FEE = $90.00 each TANK , Tanks x $90.00 $ <br /> S-- <br /> U--- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks x 180.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSIONIRESUBMISSION 1 <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK t Tanks z $110.00 f <br /> E <br /> P <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 = 130.00/hr FEE = $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE f Q <br /> OFFICE USE ONLY 'V*?Jam" C&& `3 Q 73 <br /> FROURN ""Em <br /> man <br /> ZC;P 1 LOC CODE DIST CODAMOUNT DUE AMOUNT RCVD C CK /CASH RCVD BY DATE RECEIVED PERMIT t <br /> �/ 4 `fad <br />