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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> RGROUND STORAGE TANK PROGRAM . FEE WORKSH <br /> IF FACILITY/SITE NAME <br /> A FACILITY CONTACT NAMEC Mir —.__--- -- <br /> ,/� <br /> I ----- - -- ---- -�\.i n [ <br /> L STREET ADDRESS - SITE PHONE # WITH AREA CODE <br /> F,-I � .r ry <br /> r <br /> T -- -- -- — ....... f - q0 <br /> Y CITY <br /> _ _--L-STATE ZIP CODE # of Tanks <br /> at site <br /> ..----_ —_ — <br /> A APPLICANT/BILLING NAME ` APPLICANT CONTACT NAME <br /> I MAILING ADDRESS <br /> r. <br /> APPLICANT PHONE # WITH AREA CODE <br /> N CITY STATE IIP CODE TYPE of APPLICATIONVo_ <' f rr' "'.'a 5:J� <br /> CLOSURE, INSTALLATION, KTC. rc <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A..__.... ._.----.— __.__._..._...____---.___ ._______________.....___ _ <br /> C 1986 1987 1988 1989 <br /> T <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanks 3 x $50.00 1986 1987 1988 1989 ......... <br /> A (multipTy N by fee for <br /> C each year applicable) I J�r'Y'..... � C ` ` �Drtr— —.. f--�/7!7c <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 mount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) —�-� _��_---- "------- _ <br /> O Cl.OSURE FEF = $90.00 each TANK <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) — — - _ <br /> E - <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks____ _ x $80.00 $ <br /> P PLAN CHECK (installation or Repair) -- � �^ ----�—ry — ----' <br /> L <br /> N PLAN CHECK FEE =$30.00 each SUBMISSIONIRESUBMISSION <br /> REPAIR ------'___..._----_-._------ --- ------ _._.._. -- ----_.... <br /> R TANK, REPAIR FEE = $110.00 each TANK # Tanks x $110.00 $ <br /> E ------ <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= _...._._.__ — FEE _ $35.00/hr —�_-- — FEE�= $3S.00Ihr�_.- _. $ <br /> TOTAL DUE $�/��� <br /> nFFrcl• USE aNlr <br /> IIIA II!lI �I f ll�llfl Ill ! }� II II II IRI 1191�illl !IIIIIIRI I IIII IIIn{!'11�11 I Ill nlll}I I�III ll(II(�Ill i}ilial llil iIIIIII II�II011lfl I�I��il.fil€I�l lilllll=ll100l0l311111lilll IIQ1MURIIII«Ili1lfl 1 <br /> SWEEPS-4-- CQIIP_(P LOG CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD 8Y DATE RECEIVED <br /> PERMIT # <br /> A! �I}III ISI Ill llll llp��l!IfI � �IIf V ��Iiflllf IRIllill�l l��}IIA Q 16�I I �IIRI�InII � II �U#I}i ll; i� �llll ll fll J IIII �!(liClfl�l�llll B Illi$ l <br />