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SAN JOAQUIN LOCAL HEALTH D44TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> iysav <br /> L STREET ADDRESS nrN AREA Coon <br /> 1 Q�� SIT PHO E t W — �� <br /> T__ _/ _ <br /> 61 <br /> Y CITYST Z COD 1 of Tanks 117 <br /> at Site <br /> A APPPLIICCAANT/BILLINN�GG, NN•AME i APPLICANT CONTACT NAME <br /> I MAILING AaONLI wlrN ARE CODE <br /> C A . aX 707P' � <br /> N CITY TA P'COD PPLICATION <br /> T swz��� INETALLATICN, ETC-- <br /> FACILITY FEE _ $1100,00 each SITE ADDRESS per YEAR _-- TOTAL <br /> A ._... --_-- PH— 198 1988 1589 $ <br /> V- <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks 1986 987 1988 989 <br /> A (multipby eefS <br /> - <br /> C each year appl cable) f <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter 5iount and year) -J-= - - - — — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place)� — — <br /> L -- —------- - <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks x $90.00 <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 I Tan x $00.00 f <br /> P PLAN CHECK (Installation or Repair) — — — -- <br /> L -—— - _ - - --- ---- --- <br /> A <br /> N PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUDMISSION — — <br /> -..REPAIR -.- <br /> P. TANK REPAIR FEE _ $110,00 each TANK - _ -- I Tanks x $110.00 f <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 <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> f'!GIGG G@I��IGIIGflIpGBGIIgII!GGlmP11�PlIGI9'191191��1P,�IP4GG! dB91GGm�GJVGPGiiI!G@GVCGa':IGCG9!IiIIIGGGGII.ra114fJ�GVVGGG9IGVUOGVNIi G�!!!i�dV'I�IGIiG!G�G11GIlUGiI!I"n�I�I?1:TufdI111�J�GI84111TIGIfi1GGGP9@@IIIG@VMJ�I'tIII!GGCiIT�G' IIP�VVII�j <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RC,VO CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I NN' <br /> IGgp;!�qm! !9•!!,i,! !!,rnr' !Gpfli'P�!'NG!!GiiGl!1!GV�LJGVVf,GI!!lil. ;, qVR�:G!NJIII .p61VGlll'!VIl�i11191�ITJ�gGN!IlillalCGG91�!MVIVIII�VIG II• ,IIGGGGIfJVGG!IVG�II�IG�IfV16IVG1iIIGIP.�IIVIRGIIIVd!IWPIfG4vJAGVNI6�GIIQ�,�i!Il <br /> E,G /� z �vf � t�r�� <br />