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SAOJOAQUIN LOCAL HEALTH IJOTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C <br /> I <br /> L STREET ADD SS SITE PHONE 1 WITH AREA CODE <br /> i— �• /Y1aih _ .2E - <br /> Y CITY STATE IIP CODE 1 of Tanks <br /> at Site <br /> -- <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P �r� In f- �r /' �p �"� n '',, np �/ <br /> L- - CS./�l n/,iy�p __ ( /!! ;(�v /NQ/lCr� /C�i/�54 <br /> _.-....... �( SN ( ._.—_— �_. <br /> 1 MAILING A DRESS �'�' APPLICANT PHONE 1 WITH AREA CODE <br /> C SS(o �. 6�.pCiir� _ <br /> N CITY S ATE IIP CODE E of APPLICATION — <br /> T S'f©G�' � LCEDRE. INSTALLATION. ETC. <br /> ������ --__—._— <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> — <br /> C —'1986 _---- ---1987—_- • 1388 <br /> c --Of� — — <br /> T yr1r2 <br /> I /00 — /Op O <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks x 150.00 1986 1387 1988 1983 <br /> A (multiply 1 by tee for <br /> C each year applicable) Sy SO — $ O <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x n56yea 1986P <br /> 987 1388 1989 <br /> Y (enter aiount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-plate) <br /> L... ------ - ------ -- --_- -- -..._--• - — <br /> 0 CLOSURE FEE = $90.00 each TANK —_ 1 Tanks_ x $?O.00 f <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 1 Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L -- <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUOMISSION f <br /> REPAIR <br /> P. TANK REPAIR FEE _ $110.00 each TANK1 Tanks x $110.00 <br /> E f <br /> ._._._—..-_.__..,. _-- --- -- - -..., <br /> A PIPING P,EPAIR/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/hrj_._ FEE_ 13a_OO/hr�__� FEE _ $35.00/hr� <br /> TOTAL DUE S <br /> OFFICE USE ORLY <br /> @,G@@@E�G!sG@Gi@II@G COMP CO DE D1s^• �i@@ �I@GG@1GiGG��@I.@IGGGG�!!@IG�GGG�17!�@!;7mVi@GGI@@GG@iGIGGG.I�!@I!@I:",ofITI�.G@@GGG@IC@GG@1GI@fiG@@G@ GM@GGIiI�GI@GG•1f!GG•�i ..u, <br /> T F,ODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br /> �@@�G.�� � �g�G�. ,!GGGI!IIGgG@1GIGiG.i!@@@.�I!@@IIIGIG!:I.�IIGGII�G@Gllq!';PGI@��!@IIGiGIf�IGGnGIIG@GiIIGII� G9Vil@iGIIGGGG�9GIIG@IGA6@GIGq @GGGGMGI!I@GG4GGi I�IGGGIGGGIG@GI�I@IGI@I .GIIGI�II@4111@RIIGII'I@ll'GGI'GGllu� <br />