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SATO JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> �F FACILITY/SITE NAME FACILITY CONTACT NAME c /ham <br /> I <br /> L STREET ADIIRESS SITE PHONE # WITH •RKA COOK <br /> T---s�L2�12Q—At <br /> Y CITY STAT i1P CODE # of Tanks <br /> C at SiteICA <br /> - - — <br /> A APPLICANT/BILLING NAW APPLICANT CONTACT NAME <br /> P <br /> P <br /> L.._ <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AN" CoOc <br /> C <br /> A- <br /> N <br /> T CITY STAT iIP CODE TYPE of APPLICATION <br /> ------•------'--------.'—� �- CLOauee, IWereuenaW, ere. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> AC _-..... ..._ ---- - - - <br /> 1986 1987 1988 1989 <br /> 1 — DO $ OD <br /> V - <br /> E TANK FEE _ $50.00 each TANK <br /> A (multipTy 1-bks y o 198 <br /> fee Dor - 1986 - 1381- - 1988 5 <br /> C each year applicable) f O <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH It SAFETY CODE Sec 25287 for applicability) <br /> T1 Tanks x and <br /> yea -1—:1.91C <br /> — 1987 - 1988- 1983 <br /> Y (enter aiouot and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) J — <br /> 0 CLOSURE FEE _ $90.00 each TANK # Tanks------ x $90.00 f <br /> S -� <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E — <br /> TEMPORARY CLOSURE FEE u $80.00 each TANK ---� I 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 1110.00 f <br /> F --- — — — --------_— _ <br /> A PIPING REPAIR/P,LOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I --- <br /> R <br /> --R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> When applicable) when applicable) When applicable) _ -- <br /> FEE = 130.001hr FEE = $35.00/hr FEE _ $35.0 hr $ <br /> TOTAL DUE $ A D(p <br /> OFFICE USE ONLY <br /> .Vi��V:"�.!II�V!IVRVN��II!V.I�.�;I!CVI!�I!PIIP'IVV911VIiVlVIV�IVII IIVVVVV"V@1VVIViiai!�i'�,VVVf�iV1,IV!INTI!IVi�Vi@"ISIV.VIIM�Ii�li!WII!VVVGVVr�!G"V':i!i�'d'alit!IuliVlllili�lliVlVlaillfVlVlll.�!I':IiVilililil CIIVVII111VnVV!�!IViIVVV <br /> SWEEPS 1 COMP 1 LOC CODE GIST CODE AMOUNT DUE AMOUNT RCVD , CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br /> :d111!Nf;Oi�l 1911i8!,III'I� ,NNVi!.IIrINl9!VNNfG,.l!I191!C!NN!NNNiiVN! Il lNp!I INIIjIINgINII V'y�IVf�INIVV!gi diRNININ@VGN1VIIVNIII!AVVINIIiNNIIAINfV"i!iNflnNl;.@III�ImijiIIIII�U111N�iIINNNL:GIN1�1V&V <br />