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SAN JOAQUIN LOCAL HEALTH DI TRICT <br /> OERGROUND STORAGE TANK PROGRAM FEE NORKSHE <br /> A A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> E(lo1 e 0 i <br /> I HJT=ci ✓ /��C`7�/[fG/t ci c G, <br /> L STREET ARESS <br /> SITE PHONE # (with Area Code) <br /> i ,e S. �r ✓T�ic.f pN <br /> Y CITY,5 STATE ZIP;ODE # of TANK'S <br /> y j Yui at Site TdY"d <br /> P APPLICANT/BILLING NAME /�P17G/tom✓/Glc7�i� Jen v -e_ APPLICANT CONTACT NAME <br /> P ` �G CJ7Piz.+/ elle�c2 .1Plt cL` <br /> L <br /> 1 MAILING ADDRESS X73 /-;71,-Nrf' ✓J /G <br /> C APPLICANT PHONE I (with Area Code) <br /> A <br /> T CITY STATE ZI PCODE TYPE of APPLICATION <br /> fy lvy (Closure, Installation, etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1'388 1989 <br /> T �� _ <br /> - - R Cg T $ <br /> TANK FEE _ $50.00 each TANK J <br /> F I Tanks x $50.00 1986 1987 1988 989 <br /> A (multiply# by fee for <br /> C each year applicable) ZL STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicabES <br /> I <br /> T # Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiouit and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 9 CLOSURE FEE _ $90.00 each TANK # Tanks_ ?_ x $90.00 $ <br /> U G — <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 PL Re air) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION g <br /> R. <br /> E TANK REPAIR FEE _ $110.00 eac I Tanks x $110.00 g <br /> P <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to Ian submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE f C, `= <br /> OFFICE USE ORLY <br /> SWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD (CHE /CASH RCVD BY DATE RECEIVED PERMIT I <br />