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JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEETU <br /> F FACILITY/SITE NAME --�—•- <br /> A FACILITY CONTACT NAME <br /> it_z 5 <br /> 1 I <br /> L STREET ADDRESS <br /> I 1 SITE PHONE 1 Vim ARCA CODE <br /> T Sp <br /> Y CIT <br /> SATE ZIP CODE - 1 of Tanks ) <br /> at Site <br /> F APPLICANT/BILLTH6 NAME - — — — -- <br /> P A I I - APPLICANT CONTACT NAME <br /> ��`7n r <br /> L - <br /> 1 MA ING ADOP,ESS �--_._.._..._-..._._-_--.����/ �� / C�,�/� <br /> A APPLICANT PHONE 1 NIT" ARA CODE <br /> T CITY — - - — - <br /> STATE i1P'CODE APPLICATION <br /> CLDEURE INmTALLATION, ETC. <br /> A FACILITY FEE`-{100.00 each SITE ADDRESS per YEAR - <br /> -� .__------ -------- _ <br /> 1 1906 _- TOTAL <br /> 1987 1988 1383 - <br /> V.. �- f <br /> E TANK FEE = ..50.00 each TANK <br /> F 1 Tanks _ - x'550.00 - 1986 1981 <br /> A (multiply-I'by fee for — 19-0-0— <br /> a <br /> 988 <br /> C each year applicable) — <br /> L STATE SURCHARGE = 156.00 each TANK tree CA HEA 4 <br /> 1 _—_— _ HEALTH 1 SAFETY CODE Sec 25281 for applicability) <br /> i I Tanks x156.00 1986 <br /> Y (enter iiouit and year) _ 1301 1388 <br /> I: PERMANENT CLOSURE (Removal or Closure-in-place) - •— <br /> 0 CLOSURE <br /> S FEE = t')0.00 each TANK -' — <br /> "--- <br /> J-1 Tanks_ _ x %10,00 <br /> U - -•---- - -_-.-- _ —_ f <br /> P. TEMPORARY CLOSURE (Only allowed one time for up to two years—) r <br /> E'- -- <br /> TEMPORARY CLOSURE FEE _ (80.00 each TANK -- <br /> r 1 Tanks x 180.00 <br /> P PLAN CNFCK (Installation or Repair) — " -'— -- <br /> L --- -- -------— - - <br /> A <br /> )I PLAN CHECK FEE 130.00 each SUBMISSION/R(SUOMISSION — <br /> REPAIR ---.._ —.-� -----------LE6 <br /> TANY, P,EPAIR F <br /> EE = 1110.00 each TANK <br /> 1 Tanks x 4110 00A PIPING REPAID,/CLOSURE/REHOVAL (Fees are per hour, minimum one hour to be paid on plan submi—R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (when applicable) (when applicable) SAMPLING INSPECTION <br /> (when applicable) <br /> FEE = 135.00/hr --_.FEE = 530.00/IIrI FEE = (35.OFFICF USF ON(Y TOTAL DU <br /> VSWIVO"I�1n44G4VRNIVUtlVIIJIV! lVI9N4!!pU4'19V99fJ�99!VVIV9 d !11,4ih6V9UpI;IluS811VIVUVhJ;llBfl!I4IliVI6lflVl! ➢V411V9 V�I141J@UVI��UCV?�TUVV�IVIIVIII VVli6@I8 !IVI,mIIV! Tuf6TillE f��I�IIV44N�1ViIVV�V IIAIG �1�61UVW6�?�Ug996VVAli <br /> SW1 COMP 1 LOC CODE DIST CODE AMOUIIT OUf AMOUNT Rr,VD CHECK 1/r,ASH RCVD BY DATE RECEIVED PERMIT 1 <br /> T1 .. ._ a.._.._.... .....LOL.u.-L......_.. 4 _.qy _ NIBS - — - <br /> ��� .,.411CVVI!!IVVU48!!iV!II�IIt�VOGI!f�IIV,J.'VV!! i��iVW!f�I�VVII�'IV �7�1. NS@V�iNIVI �Cpp�41VVUp�,'I�I!U4VO�Ih If�UIIIIIIVPoiVINVVUVUB9 BWJI�Ifp� <br /> ��41VIR�!VUCBVI� <br />