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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE NORKSHEET <br /> -- - - _ <br /> �__..--_--- ----�--------. . FACILITY CONIhCI NAME Dlcl-\ V1�Its��� <br /> ITY/SITE NAME <br /> Nr rN emu CODE <br /> —� --' -- SITE PHONE 1 <br /> L STREET ADDRESS - c h 5 rcl _ ar1 <br /> Y Clf STATE IIP CODE 1 0l ianks <br /> at Site <br /> -���- <br /> APPLICANT CONTACT NAME - <br /> A APPLICANyl81U1NG NAME <br /> P JCCC[` �C�— aEeE CODE <br /> L --— APPLICANT PHONE 1 <br /> I of IMG AD 59laz _ chi=_.._y.� <br /> r, �- - -_--- -_ STAT IIP CODE TYR 1 <br /> APPLICATION <br /> N CITY <br /> ,y uee. INET111111f 10N. e•e. auL,,r,1� <br /> - - ---Is <br /> = -- -- <br /> ___- - -� <br /> TOTAL <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> A1988 <br /> 1386 -— 19A7 1983 _ LL/-- ------------- <br /> T — ---- .... ----�_._ --- -— ------- -— -._-. <br /> E TANG FEE 150.00 each TANK <br /> f 1 Tanks _ w 150.00 1986 1987 <br /> A Imo1Hp1y 1 by lee for - <br /> C tach year applicable) �---�---- _� -- --------- - -- <br /> I ----- -- <br /> L STAYS SURCHARGE ! 156.00 each TANK (see CA HEALTH L SAFETY CODE Sec 252819VpplIca 'litV <br /> -- ----- -- __ f ]��q - <br /> y.. I 1 ianks w 156.00 1386 1391 1388 I'fu3 _ — <br /> Y (enter &&Dunt <br /> C• PERMANENT CLOSURE (Removal or Closure-in-place) -- - <br /> L ._....--- ---- ..._ �1 Tanks_ s 130.00 1 �0 <br /> 6 CLOSURE ra • 130.00 each TANK -- --- --- <br /> U --------- ---- ---- _ <br /> R TEMPORARY CLOSURE (Only alloyed one time for up to tyo years) ------ <br /> E ---- - - — ---- ---- 1 Tanks. ... w 190.00 1 <br /> TEMPORARY CLOSURE FEE ! 180.00 each TANK _---------- <br /> P PLAN CHECK (installation or Repair) <br /> A 1 <br /> II PLAN CHECK FEE • 130.00 each SUBMISSIONAESUOMISSIOII --_ --_`---_ -.-__._-_--__-__..-------- <br /> REPAIR --- -.._... --- --..._.. <br /> R iANY. REPAIR FEED 1110.00 each TANK 1 Tanks__:___ w SI10.00 A <br /> T --.._.-.._ . _.._. .. _.._.. - <br /> E -_...____ -- - ---- ---......_--...---.... -- -- --- _... -- - - <br /> r -.--------------....._._ --- - - --- - -- Q <br /> A PIPING REPAIRICLOSURE/REMOVAL (revs are per hour, minimum one hour to be paid an plan subm"Rtj <br /> ink <br /> - <br /> - �o <br /> R UNAUTHOPIEED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING 1117 C1;Iftgl QUI <br /> )when applicable) (when applicable) <br /> When applica VIR�F�EA(I �OUNjL _..... <br /> _ __ ... _..... -- HE ICES <br /> rNQIV� --- <br /> TOTAL DUE 1 <br /> OFFICE USE ONLY `r�+ ! rcyt a p& D f3 <br /> •p MR LOC CODE DIST CODE ANOUIII DUE AMOUNT RCVO CHEC /CASH RCVD OY ,DATE PTCEIVED PERMIT 1 <br /> � ��- � n AIA�Ep�pNR�ff .�A9Fi�1�IINl�llhl�I!9� <br /> V <br />