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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "R NO STORAGE TANK PROGRAM - FEE NORKSHE <br /> F FACILITY/SITE NAME <br /> is <br /> A FACILITY CONMT NAME <br /> C J( O,r,X /'�ccr kZ7 <br /> 1 /\Jr� .t f' <br /> L STREET ADDRESS SITE PHONE t WITH AREA CODE <br /> T_ 235 . Sca ti#o� fedQ <br /> Y CITY STAT IIP CODE t of Tanks <br /> ruer' iu{� QST, at Site <br /> A APPLICANTIBILLING NAME <br /> P APPLICANT CONTACT NAME <br /> �� Lf Gr 13n / <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> - <br /> N CITY STAT IIP <br /> T CODE TYPE of APPLICATION 5'4 Ale re-nra!;4 <br /> CLOSURE. INSTALLATION, ETC. <br /> Gen. 01- <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A TOTAL. <br /> C 1986 1987 1988 1989 <br /> T <br /> Vco <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks 3 x $50.00 1986 1987 1988 1989 <br /> A (multipry-[-by fee for <br /> � each year applicable? S d Q vb 5 d E,e /S d 47" $ � � <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> I- <br /> T I Tanks ?_ z $56.00 1986 1987 1988 1989 <br /> Y (enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L - <br /> 0 CJSURE FEF _ $90.00 each TANK I Tanks x $90.00 $ <br /> S __ ----- <br /> U- _ <br /> R TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $80.00 S <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 $110.00 $ <br /> E --- - <br /> P -- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid an plan submittal) <br /> I <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $ ��L <br /> OFFICE USE ONLY <br /> us-INUMN OWN MOM 11HREPOW <br /> SEER COMP i =CODEDIST AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT It <br />