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o ,1. <br /> . 1 <br /> l SS JOAQUIN LOCAL HEALTH &TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> ILL— <br /> L STREET ADDRESS SITE PHONE # WITH AREA CODE <br /> �._ S T IIP CODE # of Tanks <br /> Y CITY ,�+ at ,Sate <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P , <br /> P tri�`c�c,�• �++,,�� �.- F t �'��C,�,� _ ✓ ._T 1""arc- L- <br /> I MAILIN�i ADDRESS APPLICANT PHONE # M- AREA cone <br /> A IIP CODE TYPE of APPLICATION <br /> N CITY G //� :1��TjiCLOSURE, INSTALLATION, ETC. <br /> r! ' �T7 � 1 �y <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ......... _.._...—____._.._..._...._.__.__.._._._ ..._...,_.__..._...,__..._.._._._.....__...___..____.__.._..__.....---..__._.. ..................... <br /> ...,. <br /> C I9B6 1987 1988 1989 <br /> T __._..__ _�____._.. _ . ---.---.___-._ _.._.__._...._._ ----___.. ------- <br /> E <br /> E TANK FEE = $50.00 each TANK <br /> F # Tanks _ x $50,00 19$6 1987 1988 1989 <br /> A (mul ti pfy_V by fee for <br /> Bath year applicable) $ <br /> L STATE SURCH = $56.00'�Ach TANK (see-CA HEALTH 4 SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x $55.00 T 1986 1987 1988 u 1989 <br /> Y (enter amo5ht and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = $90.00 each TANK # Tanks _j _ x $90.00 <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanksx $80.00 8 <br /> ...._._._..._._._...____..__ <br /> P PLAN CHECK (Installation or Repair) p , <br /> L <br /> A <br /> N PLAN CHECK FEE = $34.00 each SUBMISSION/RESUCMISSION : <br /> REPAIR _ <br /> R TANK, REPAIR FEE = $110.00 each TANK �# Tanks _____ x $110.00 $ <br /> E _ <br /> ._...'..__.....__ _.............__--_.._.._--.-_._ <br /> 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 IfISPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> ..FEE ._..$30.4__0/........ -_ _ __.. ....__....__._._..._....___._ ......._.._.___-_____.__..._._._..,._..—__......__.._..._. . ..—__.....w.._._,.__._.___........__.._,.._._... <br /> hr FEE $3,.00Ihr FEE _ $35,OOIhr11 $ <br /> TOTAL DUE $ fG_ <br /> OFFICE 115E ONLY <br /> ! !! n .............. <br /> YI! �E!��! ! � ► �1z'!ii� NI ! '!II!I11w!�I�I? I<I!'I!!LEI!�lilll�!!!I!!II�illR!I'il!Ili','!!!��Ii111111Ilif�lll!fil'Giillll!IIlll !i'liriltlll I;I[nIIII�CII!�l�il�il!I�!IIIA!I!. ill!I!li!!�li�ll !ilf6i11111P�! <br /> „...!II..I.. l�Il� 1,l..lei,�l,lll il,.lUl!911�!�4,�I, ilk! Wl,ll�a,�!I JIIIe�,t�� IOC�6,�,,1 Ti l��ll { <br /> SWEEPS I COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT I <br />