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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ <br /> UNMOUND STORAGE TANK PROGRAM FEE WORKSHEET A <br /> .rel—F FACILITY/SITE NAME — FACILITY CONTACT"NAME <br /> • � (Zc 9J 9Y8—d/zJ� <br /> /,J�s- M�r�,e s�✓yam, /A4e-. <br /> I q <br /> L STREET ADDRESS <br /> SITE PHONE t WITH AREA CODE !'QJVVYIIft{qr <br /> Y C1iYSG—"T�-- T CODE �t of Tanks <br /> o C at Site ONS �xJ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P C� .�S% /� /rrETaZSPOzi//LG' mac, /�I(GiM �GSs[�.I� <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> T CITY STATE ZIP CODS CIDEURE,PE of AINSTALLATTION, ETC. L L0.Srla?� <br /> STocmc�� on/ — s' <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A...— — -- -- — <br /> T —1986— — —1987— t-1988 —19A9— $ <br /> [ J <br /> V -- <br /> E TANK FEE _ $50.00 each TANK <br /> ------------ <br /> - —-- —._...._ ----._...----— -- — — <br /> F t Tanks _ x $50.00 1986 1987 1988 <br /> A (multipry f_ 1989 <br /> by fee for --- ----------- <br /> C each year applicable) — $ <br /> I -- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 4 SAFETY CODE Sec 25287 for applicability) <br /> T t Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter mount and year) — — — <br /> C PERMANENT CLOSUR (Rev 1 or Closure in place) — — <br /> O CLOSURE FEE _ $90,00 each TANK t Tanks__(__ x $90.00 <br /> U- <br /> R <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E — ------ <br /> TEMPORAP,Y CLOSURE FEE = $80.00 each TANK t Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) — — <br /> L -- <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK [LTan — x $110.00 $ <br /> E-- --- <br /> P — ---.---_� _ <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 = $30_00/hr _ FEE = $35.00/hr[ --- — FEE = $35,00/hr— — $ <br /> TOTAL DUE f O — <br /> OFFICE USE ONLY <br /> 9V�21' IB��IOIftMIV��iI IB�B9�I�I�V11 IIMIIB�11�61iVV�II�QB�PII�I�IIVNI��l�l161 'II���IQVIIVV�AVIIIIIIIm11�1811 VIIV911WNVII�IVIIRII��IDIIAIN�1 I���IIIIIMI�I�II pV�IUl�l@�I�III �IV�tl1�11�19P <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT t <br /> ---- -- —... -- -- ._._........._.._... ..................... — ...--------- <br /> �fla�unm�muoMI ¢�i��u��ou �o�� <br />