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SO JOAQUIN LOCAL HEALTH *STRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> _._..__..._........_�—_ <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> � Lt. SSG Y`lL-rrt�►t-�C.c� ��r �-i?�r �� �" f S r1 �'�' <br /> L STREET ADDRESS - -- SITE PHONE I WITH AREA C009 <br /> I r7Al Ct C ca-,nj <br /> Y CITY STATE IIP CODEI of Tanks <br /> =" jat Site <br /> F APPLICANT/BILLING NAME APPLICANT CONTACI NAME <br /> ,��.f <br /> P 'r` i C ! . L�tJ f S'1'l e l� _ �,iC.� / 5/) e <br /> I MAILING ADDRESS APPLICANT PHONE I w'Tw AREA ME <br /> N CITY T E 3IP`CO[p�E TYPE of APPLICATION <br /> _T tMETALI.ATIQR. ETC. C/r <br /> 0JU.0 rr <br /> FACILITY FEE $100.00$100.00 each SITE ADDRESS per YEAR TOTAL <br /> A _...._.......... <br /> __._..._..........._ <br /> C 1986 1987 1988 1989 <br /> T _— <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks x $50,00 1986 _1987 _ 1988 1989 <br /> A (:ultipTy_D-by fee for <br /> C each year applicable) <br /> 1 _ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> T $ Tanks x $56.00 _ 1986 1987 1988 — _- 1989 <br /> Y (enter iiouiit and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> D CLOSURE FEE = $90.00 each TANK $ Tanks 1 x $90.00 -- $ <br /> S _ _ ----- ,_ _ - -- <br /> cD <br /> U <br /> P, 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 /> P PLAN CHECK (Installation or Repair) <br /> A. ._._____.._ __..._._ .. ._._ _. .___.___.__ _.._ _._._— _ —..._...__.__ <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUCMISSION $ _--- <br /> REPAIR <br /> P. TANK REPAIR FEE _ $110.00 each TANK II Tanks x 1110.00 $ <br /> E ------ <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 _ $30.001hr FEE -- $35 0; FEE_,: $35.00/l+r <br /> TOTAL DUE f� — <br /> OFFICE OSE pull' <br /> �III �9 " ��l�lli�l�� <br /> SWEEPS i COMP I LOC CODE DIST CODE AMOUNT DUE AMOUHT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT t <br />