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SAN JUAUUIN LUCAL HEALTH DISTRICT <br /> VDERGROUND STORAGE TANK PROGRAM FEE WORKS' <br /> F1FACILITY/SITE NAME <br /> FACILITY CONTACT NAME <br /> I __ �ee rocer I Sack_ 8QZ,Zarro- _ <br /> L STREET ADDRESS \/ SITE PHONE 1 WITH AREA CODE <br /> 1 -j--- --T —- <br /> T——6 �a —E,__�Al�c fer oo c�•/ -- -- - .._ .—_.9._36 8� <br /> Y CITY A E IIP CODE 1 of Tanks <br /> _ at Site <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P N�A <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> WTI <br /> C[TY IIP <br /> BE <br /> TYPE of APPLICATION _ <br /> T CLOSURE. INSTALLATION. ETC. <br /> FF�A9LLITY FEE = 1100.00 each SITE ADDRESS per YEAR _ TOTAL <br /> .--e-- --- -- --- -- <br /> -, I� CQOc -•�-0.-11987---1988--1 --1989 - ----- s-- <br /> E TANK FEE = $50.00e ach TANK— <br /> F 1 Tanks _ _ x 450.00 1986 1987 1988 1989 <br /> A (wltipfy I by fee for <br /> C. each year applicable) Pp�. --_— --- - - -- — <br /> [ ------ — - _—.__.---- f <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY COOS Sec 25287 fur applicability) <br /> - <br /> T 1 Tanks x $56.00 1996 1987 1988 1983- <br /> Y (enter iiouit and year) PA — <br /> r — <br /> -- � om_____ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) - — <br /> 0 CLOSURE FEE = 130.00 each TANK 1 Tanks x $90.00 f <br /> S -- --�—.— -- —__— _ <br /> U ..-----—---- --- -- --- — <br /> P, TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x 480.00 f <br /> P PLAN CHECK (Installation or Repair) — <br /> L — — ----- — - -- ..._..------- <br /> A ___—---- — --- <br /> IN PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION -- — f <br /> F --------- _— ----- --- —_ <br /> REPAIR -- - --- --- <br /> R TANK REPAIR FEE = $110.00 each TANK 1 Tanksx $110.00 f <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) _ (when applicable) (when applicable) <br /> FEE = 130000/hr� - FEE _ $35_00/hrl---- -� FEE = $35.00/hrl f <br /> TOTAL DUE CO o 0 <br /> OFFICE USE ONLY <br /> IQINIMIQIIII0I9IIQQiIIIQIIQIIIQII!!IIItQIIQIIQQIQQ9I000QQIQ!IQIQQI!QII QITEM IIIIQQIIQ1QIIIQQBQQIIIQIQQQQ!IIIIQIIIQIIIII'IIQIIQQIIQQIIIIQQQIIIQIIIIIIIQgQIIIIQIIIIIIIIIII@.IIIIIIQIQIIQIIQQQQIIQIQIIIIIIIIIQIIIQQIQIIIIIIIQIIQIIIi QVQQIQI@QQQIQI!�IIQIQIIIQIIIIRIIIIIIIQVQQIQIQIIIQQIIIQQQ19111111QIQIIQQi <br /> II� <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT P,CVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> R <br /> pE�pFQ pQ�IIIIIIIQIIIIQIIQVII9IIIQQIIQ�IIIIIIIIII�IN711ll!I00041gQ011 I)�IQI�IQIIQIIIQ�IQQVQQQ IQIQ.QII�IIQQIIIQQQQQQQQIQQQIIQVQQIQV� <br />