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SAN*OAQUIN LOCAL HEALTH DIORICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET ---_._ <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C —(LTJ O N><cC�U L tL1Gr � <br /> I SITE PHONE t WITH AREA CODE <br /> L <br /> STREET ADDRESS Locos-T- <br /> T <br /> _=of <br /> T�-- _� � - — STATE ZiP CODEsY CITY � � _4 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P _ _ - <br /> -� APPLICANT PHONE t <br /> L...._-...___.._.._......}�tI{.Y.m..E#,i.�-_-_-..-,..-._._.._ WITH AREA CODE <br /> I MAILING ADDRESSRrEMCEIVED <br /> STATE ZIP'CODE TYPE of APPLICATION <br /> N CITY SEP 2 2 1989 CLOSORE, INSTALLATION. ETC. <br /> -- <br /> --- — <br /> FACILITY F - 5 per YEAR TOTAL <br /> T 1986 1987 1908 1183 <br /> s <br /> E TANK FEE _ $50.00 each TANK __............._ <br /> F t Tanks _� _ r $50.00 1986 1987 1988 1989 <br /> A (multtpiy 1 by fee for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH b SAFETY CODE Sec 25287 for applicability) <br /> T t Tanks x $56.00 1386 1987 1908 1983 -- <br /> Y (enter ziouot and year) — $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L..---.---_____.__—------ <br /> t Tanks f <br /> 0 CLOSURE FEE _ $90.00 each TANK x (30.00 <br /> -- -- �— ^__ <br /> S <br /> P, TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E---•---_._--------._ _..�—._.--__.___._—_.. t Tanks _ x $90.00 $ <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK � ��^__. <br /> P PLAN CHECK (Installation or Repair) <br /> A f <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION — <br /> REPAIR _ -- <br /> P. TANK REPAIR FEE _ $110.00 each TANK t Tanks------ x $110.00 $ <br /> ........ <br /> .. _. <br /> P <br /> A 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/hrl FEE _ $35.00/hrI FEE _ $35.00/hr $ <br /> TOTAL DUE $ �--� <br /> OFFICE USE ONLY <br /> ! I!Ifl!IflIPfl"PIIVI�NI@flllfllllfl!14!IflIN!PAIflAIa!9!flP'u19flfil�!J�IIfl: Wllllfl�l;fl@Jl�flliuii1�lANflflCfiaJGfl�19i01flTd@,",4�10flflIIJIIGflfl!!I!III!.�Rifll "!Ilflfl!P�'d!JI�GIIfllflff�1lifllfllfll'Iilflli!!Illlf!C;ifiiGl1illfi.lillfl�flfl!ICfl!'�a!IflililflilGlllflllflfl@ flVfrl!!fl!NImIIVI��!�IGIBflIPa�lA.h <br /> SWEEPS $ COMP t LOC CODE GIST COOS AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATES RECEIVEDPERMIT t <br /> f <br /> !�%� ! ! Ali"!� f91tlV�l IIiIP,pJlfllllflglfl'fllflG�l!!I! IIPIi!! !!Iflfli Ifl IIII'�lfllH �@liflli fl!, Iflfll Q!" IIV Plflllf@fll' IIII�P' flflAII N Ilfll!flllillflll�ll�l Illlllflfl II !lfllflfl911 IIIIIiIIfG!11�IRIIVIllflflllflfll'i� <br />