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F I JOAQUIN LOCAL HEALTH ISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> e�ir G u, iu �r . /cru We-- <br /> L STREET ADDRESS <br /> N �rd �� SITE PHONE 1 l ith Area Code) <br /> T /G6 - Y / i <br /> Y CITY STATE ZIP CODE Y of TANK'S <br /> 11 at Site <br /> A APPLICANT/BILLING NAME Il�j APPLICANT CONTACT NAME <br /> 1 <br /> L 5 `tom <br /> Ales <br /> C MAILING ADDRESS <br /> 7 �r APPLICANT PHONE 1 (with Area Code) <br /> A <br /> T CITY STATE -21P CODE TYPE of APPLICATION <br /> c G faU Closure, Installation, etc.) <br /> A FACILITY FEE = $100.00 each SITE ADORESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> I <br /> I <br /> V f <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks x $50.00 1986 1987 1988 1999 <br /> A lwltipfy f-by fee for <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) 1 <br /> T 1 Tanks x (56.00 1986 1987 198A 1989 <br /> Y (enter ii5at and year) <br /> t <br /> EPERMANENT <br /> oval or Closure-in-place) <br /> each TANK1 Tanks z 190.00 y allowed cone tine for up to two years) <br /> _ $80.00 each TANK 1 Tanks..... $80.00 <br /> ----- k J <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A _I <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE = 1110.00 each TANK 1 Tanks x $110.00 <br /> P $ <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, ainiaua one hour to he paid on plan subaittal) <br /> R <br /> (when applicORIZEDable) <br /> RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when appliublel INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35,00/hri IFEE _ $35.00/hr <br /> E <br /> f <br /> OffitF ISE ONLY TOTAL DUE <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1 ASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 3a3 S °` 5- �" s = C�3 1- Y d� <br /> .Y:. •b.'Y,. .ho y•i'i, '4+' _:9'Mi•. .C.Rxy.:Y•r# <br />