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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> GROUND STORAGE TANK PROGRAM FEE WORKSHEEO..___ <br /> FACILITYISITE NAME FACILITY CONTACT NAME <br /> L STREETADOWSS SITE PHONE # WITH AREA CODE <br /> TA ........... <br /> Y CITY] STATE ilfi CODE I of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> F <br /> L ........................................... <br /> I MAILING ADDRESS APPLICANT PHONE-1 wires AREA c`D!�j <br /> .............. <br /> N TE <br /> CITY !IP CODE T�m APPLICATION <br /> T V_�j2j <br /> 0 UR INGTALLATION, ETC. <br /> I <br /> . ............... <br /> FACILITY FEE $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> ............................................................. ............- . ... ...........19 )'388 1489 <br /> .... <br /> C 1986 <br /> T <br /> V .............. ------ <br /> E TANK FEE = L'O.00 each TANK <br /> -.._-..._.1......... ....................... ............... ......--11-.1................ <br /> F # Tanks _ x 150.00 1986 1987 1988 1909 <br /> A (multipfy_ by fee for ..........-------- <br /> each year applicable) <br /> .......... ............ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> ----------——---------------------------- ------------------ <br /> T I Tanks x 556.00 1986 1987 1988 1981 <br /> Y (enter ifflouht and year) --------- <br /> C PERMANENT CLOSURE (Removal or Closure-in-plate) <br /> ..................... ........ <br /> 0 CLOSURE FEE = 00.00 each TANK I Tanks— x $90.00 <br /> U ................. <br /> P,TEMPORARY CLOSURE FEE = $80.00 each TANK T111OR111 1L11U11 (Only allowed on, time for up to two year,) <br /> E <br /> .3 1 Tanks x $30.00 <br /> ........................_­___........................ .............. <br /> P PLAN CHECK (Installation or Repair) <br /> L ------------ <br /> A <br /> IIII PLAN CHECK FEE = $30,00 each SUBMISSION/RESUBMISSION <br /> 'J'P*E_'P"_A'_1'_R............................ .......................... <br /> ..........._­...................... ....... ............. <br /> P TANK REPAIR FEE $110.00 each TANK I Tanks x $110.00 <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 /> ...................._-1......... . __-._ <br /> .. ....._.....__.._..........___w.. ........... <br /> FEE = $30.001hr FEE $35.001hT FEE = $35.0 1 r <br /> ..................... <br /> TOTAL DUE 5 <br /> OFFICE USE ONLY <br /> 11119111119,011 1101111IT11141010 OWN 10111111111110311111 i 1111111 RiTIRM11111110 135 1111110910M <br /> ;WEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCYD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> .......................................................................... ..................................... <br />