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Sk IQ JOAQUIN LOCAL HEALTH--viSTRICT S, b ,4 '1 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY/SITE NAME FACILITY CONTACT NAME <br /> � ��� ko :e. , s <br /> L STREET ADDRESS SITE PHO 1 WITH ARRA Doc <br /> Y CITY / STATE ZIP CODE 1 of Tanks <br /> cf� S _ at Site — — <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> 1 MAILING ADDRESS �(��� p APPLICANT PHONE 1 WITH ARLA coot <br /> A L1_L___ALB,offQap <br /> N CITY f�-� STATE 21P'CODE o P lTCATTO <br /> T \V CLOG YRc, 1 mrALLATI arc. <br /> --- .—_ �I --_ <br /> FACILITY FEE = 1100,00 each SITE ADDRESS per YEAR — TOTAL <br /> A ....__—_._— — - 0 <br /> C <br /> �986�—_-1987—_ 1988 —« 1989 <br /> 1 <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> —_ --- <br /> —_ _.._8O— ---._......—._. — E F 1 tanks 3_ x (50,00 1986 1987 1988 1989 <br /> A (multipTy_I by leach year appli -- — <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25187 for applicability) <br /> I 1 Tanks ,�_ 1 156.00 1986 —1987 1988 1989 <br /> Y (enter acount and year) -- <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) —�— <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks x $90.00 1 °Q <br /> U -- -- — <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK $ Tanks 1 $80.00 f <br /> P PLAN CHECK (Installation or Repair) -- — — <br /> L —_ __— _ — ------ -- _ <br /> A <br /> H PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR _------ —�—�— —_-- <br /> P. TANK, REPAIR FEE _ $110.00 each TANK 1 Tanks <br /> E. x 1110.00 f <br /> - - <br /> _._. <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 = 130.00/hr FEE = $35.00/hrj FEE _ $35,00/hrr $ <br /> TOTAL DUE s <br /> OFFICE USE ONLY <br /> MI �C�V�llBIfRR�. V9R VN ZVE VRV�VC �ViV R .i, R RR�kR 9R GVV �dJ?I VRRGI;GV! aRRIIRVPIIumVlu'V°Ty61ViiIRwi VII11!29CV!+ VI CRN�Ji " �I�IVp 9 w,�V?� <br /> ! t COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RC VD CHECr UrASH RCVD BY DATE PECEIVEO PERMIT t <br /> Ei� 7 m VRVVI RVRMRERR!V JiIRu�168Ru"9RRIIRIU RRRV 1VPIGN6P�iV millI�i 11P,1V11P <br /> SNEEPS <br /> lD v4' E�1'P�yNs�� ,,R� 8RV�f 1, a VR;tpi1 . RVVk4�VVVVIR�GEi�C�V��RVCR@U <br />