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1 <br /> SAPJOAQUIN LOCAL HEALTH *STRICT <br /> UNDERGROUND STORAGE TAR PROGRAM FEE WORKSHEET_..._._...,___._ <br /> • ................ <br /> FACILITY CONTACT NAME <br /> FACILITY/SITE NAME <br /> t: <br /> SITE PHONE I WITH AREA CODE <br /> L STREET ADDRESS <br /> T TA I of Tanks <br /> Y CITY <br /> at <br /> ......... APPLICANT CONTACT NAME <br /> A APPLICANTIBILLING NAME <br /> P ------------ <br /> P I WITH AREA CODE <br /> L� .................... APPLICANT PHONE <br /> I MAILING ADDRESS <br /> TYPE of APP <br /> 'C 'LLATION TC. <br /> IIP . IT'L <br /> PITY CLOSURE <br /> TOTAL <br /> FACILITY FEE i10o.00 each SITE ADDRESS per YEAR ............. <br /> ............. ......... ............... <br /> A 1987 1988 1989 <br /> 1986 <br /> T <br /> E TANK FEE $50-00 each TANK1989 ....... <br /> ............ .........................-1................... ............. 19819.__.............__..__...... <br /> . ........... <br /> F Tanks x 150.00 39 <br /> 1986 <br /> A ultjpT�-Vby fee for <br /> C each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25297 for apPlicabilitY) <br /> T I Tanks x $56.00 1986 1997 1183 1989 <br /> Y (enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) �2-T—"It of <br /> L ...............-—-----------------........... Tanks s ---- x <br /> 0 CLOSURE FEE = %J0.00 each TANK -=--------- — <br /> U <br /> R TEMPORARY CLOSURE (Only alloyed one time for UP to two Years) <br /> E.1 I Tanks <br /> TEMPORARY CLOSURE FEE = sB0.00 each TANK ------ x $80-00 <br /> .......... ....... <br /> ................ <br /> P PLAN CHECK (installation or Repair) <br /> ...........------ <br /> N PLAN CHECK FEE = $30.00 each SUBMISSIONAESUBMISSION <br /> .................... <br /> REPAIR --------- - <br /> R TANK REPAIR FEE $110.00 each TANK ------- <br /> E ....................^ <br /> ..........I-------------------- .......... <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I ................. I-------- <br /> R UNAUTHDRIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (whFEE en applicable) (when applicable ......... <br /> E =—t 3 <br /> ............ <br /> ' <br /> j_...1EE = 131.00/hr FE <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> qv lop, 11111 In. MINIM, '"I1.011111 1111. I I I I I I I INTENDER,Imul <br /> AMOUNT RCYD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> SWEEPS A COMP LOC CODE. DIST CODE AMOUNT DUE .............. <br /> ........... I...........I-- .1-L" .......... .............................. <br /> 0 --2— <br /> ��'01111�� <br /> I I� M <br /> �'iiilo <br />