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SAN JOAQUIN LOCAL HEALTH B TRICT <br /> - �dNDERGROUNO STORAGE TANK PROGRAM FEE WORKSrt <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C <C( A ISI <br /> I <br /> L STR D R SSITE PHONE Y (with Area Code) <br /> 1 vQ SAC✓YVKC f, <br /> �+ <br /> T <br /> Y CITY �,,��iI,, STATE IIP CODE t of TANK'S <br /> 0i-- .br-,jr C at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> LP <br /> I MAILING ADDRESS APPLICANT PHONE I (with Area Code) <br /> C <br /> A <br /> N CITY STATE 111 CODE TYPE of APPLICATION <br /> T (Closure, Installation, etc.) <br /> i <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 19881989 <br /> T <br /> I <br /> V F 4 <br /> E TANK FEE = $50.00 each TANK <br /> F I Tankx $50.00 1986 1987 1988 1939 <br /> A (oultip y 1-by fee for �y <br /> L STATE SURCHARGE = $56.00 each TANY, (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks.,_ x $56.00 1986 1981 1`988 1939 <br /> Y (enter amount and year) <br /> L PERMANENT CLOSURE (Removal or Closure-in-place) l� <br /> S CLOSURE FEE _ $90.00 each TANK I Tanksx $90.00 $ <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 I Tanks x $80.00 .� <br /> L PLAN CHECK (Installation or Repair) ( 2 <br /> A 7A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R l� <br /> EE TANK REPAIR FEE _ $110.00 each TANK / Tanks x 1110.00 $ <br /> A - <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to he paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $34.00/hr FEE _ $35.00/hr IEE _ $35.00/hr $ <br /> TOTAL DUE $ ` 8 <br /> OFFICE USE ONLY <br /> s+c., <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> r, 'r is:;P� ,.ShwmYA <br />