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SAN ,6OAQUIN LOCAL HEALTH DISTRICT <br /> ERGROUND STORAGE TANK PROGRAM FEE NORKSH <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> L STREET ADDRESS //at t /e/41 j SITE PHONE # (with Area Code) <br /> I <br /> T <br /> Y CITYr S TEZIP CODE # of TANK'S 3 <br /> at Site <br /> A APPLICANT/BILLING NAME �yn�f'Cfy/✓ /dlf�Eii Se144/Ce APPLICANT CONTACT NAME <br /> P <br /> P jv'CJ�eh.✓%Lte7lic fe/Z <br /> L <br /> I MAILING ADDRESS <br /> C x73f� j�c-/st•r �lfC APPLICANT PHONE # (with ArV Coe) <br /> /s d <br /> N CITY S To c`( '� STATE ZIP 9DE / TYPE of APPLICATION <br /> G jj r-b� (Closure, Installation, etc.) G�cS V4 it <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> I <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanks=yby <br /> 0.00 1986 1987 8 1989 27 <br /> A (multipe For <br /> C each yable) <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH i SAFETY CODE Sec 25287 for ap g L Hfq <br /> I <br /> T # Tanks_____ x $56.00 1986 1987 1988 1989 <br /> Y (enter amount and year) <br /> $ <br /> L PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE _ $90.00 each TANK <br /> S # Tanks- x $90.00 $ <br /> ---- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK # Tanks x $80.00 $ <br /> P PLA v <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> R WI[RF ' <br /> E TANK REPAIR each TANK # Tanks x $110.00 $ <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, min our be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $ p "u <br /> OFFICE USE ONLY <br /> SWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVDCHEC 1/CASH I RCVD BY I DATE RECEIVED PERMIT 1 <br />