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SAN JORUIN LOCAL HEALTH DIS# CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET _. <br /> --- - --- - --------. _—._—......---....--------- <br /> IfY FAC(LITY/SITE NAME FACILITY CONTACT NAME <br /> E ��� Lab�4p `vl�becs <br /> L STREET. ADDRESS <br /> SITE PHONE 1 WITH AREA Coos <br /> ►lug N- l(7Ason Ws► _; Lo - ,q <br /> Y CITY TAE ZIP CODE 1 of Tanks <br /> SiocKFa (?S__ at site — — -- — - <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P -CLS <br /> L.__ APPLICANT PHONE 1 WIT" AREA GREE <br /> I MAILING ADDRESS <br /> A--..-�' -:•—_--_—_ °�.--------- � <br /> N CITY 1 STATE ZIP'CODE TYPE of APPLICATION <br /> T — C�oeuRE. IHETAUArIEH, ere.- <br /> _ ...--------- ----- <br /> FACILITY FEE = i100.00 each SITE ADDRESS per YEAR TOTAL <br /> IEi.;86• - --..._1987 —1388......._ ..... <br /> E TANK FEE = 150.00 each TANK <br /> F I Tanks r 150.00 1986 1387 1988 1989 <br /> A (multiply_1_by lee for — 1 -- <br /> C each year applicable) <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH Z SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x 156,00 1386 _ 1987 1388 1983 <br /> Y (enter iiHu t and year) 1 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L - ----..... __— ----- -- -- - -- - _-.------._-._.---__ <br /> 0 CLOSURE FEE = 190.00 each TANK I Tanks x 130.00 f y'(7 o d <br /> S <br /> U. <br /> ----- --- —_— <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMFORAP,Y CLOSURE FEE = 180.00 each TANK I Tanks x 180.00 <br /> P PLAN CHECK (Installation or Repair) v— - <br /> A <br /> 11 PLAN CHECK FEE = 130,00 each SUBMISSION/RESUBMISSION 1 <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK 1 Tanks____ _ x $110.00 1 <br /> -- - - ------..__--_ - .�� <br /> _ <br /> F _-_..^_------ - --- —_ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I -- --_ -- - --- — - - ---------------- - — - <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (When applicable) (when applicable) (when applicable) <br /> FEE = 130.00lhr FEE = 135.00/hr FEE = 135.00/hr i <br /> TOTAL DUE Is <br /> offlCE USE ONLY <br /> MR"J�99VVI111VVP!NMN.,110J1I9A!RA1RI11112, 11112iiV 11111110 COREI!1 3111.1li <br /> SWEEPS 1 COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHEC IICASH RCVO BY DATE RECEIVED —PERMIT 1 <br /> Ec���IRI � 11� IIIa�Rll��,mlI� �IVfII�V��IIIRV11 1111Il il �J �IVIIIVIR.RIiIIVII� VVIIIIIVV pVIIRI�I@VVIIIVI i „NVIIINRMIV I�MflN� V�V�I@VVVIIR�II.�N9h9C-0�I�RVOrVVIu <br />