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SAI. JOAQUIN LOCAL HEALTH D.,3TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FI FACILITY/SITE NAME FACILITY CONTACT NAME <br /> ,H <br /> 'I — <br /> L STREET ADDRESS SITE PHONE # WITH AREA CODE <br /> Y CITY STATE ZIP CODEJ <br /> # of Tanks <br /> at Site <br /> ________�_._ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P C C <br /> P <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> N CITY STAT ZIP•CODE TYPE of APPLICATION <br /> T CLOOURE, INSTALLATION, ETC. <br /> FACILITY FEE $100.00 each SITE ADDRESS per YEAR-_._._.....__..._ _ ..._...._...._..._....._..._..._.._____.._........_.__.__.__._—._ TOTAL- <br /> C 1986 1987 1988 1989 <br /> T <br /> I 3 <br /> E TANK FEE _ $50.00 each TANK <br /> _ . . -I............. ............._..__.....................__._._...._......_.._.................._.___ .____—____._._._.._.._ ._.._..__........_............_ <br /> F # Tanks x $50.00 1986 1987 1988 1989 <br /> A (multipTy-i-by fee for .......-....... <br /> ____ <br /> C each year applicable) f <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x $56.00 1386 1987 1988 1989 <br /> Y (enter mount and year) ---- — -- - ---- - -- --- <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L...................._...._..........._........_._.__._........_.—.__.__..____.________._........ <br /> _._.__..___..___._....__-_ <br /> 0 CLOSURE FEE = $90.00 each TANK # Tanks x $30.00 f (Cc <br /> U ................ <br /> _.._.___..._......_...__.._._._._.._.____ -- <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 f <br /> P PLAN CHECK (Installation or Repair) <br /> !N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION ' `'' "�• <br /> REPAIR � E TAL HEALTH <br /> R TANK REPAIR FEE _ $110.00 each TANK Tanks >P <br /> --- <br /> 4"Ip <br /> " USERVICE f <br /> E --- <br /> _ _ _ _ _._ _ __..._._ <br /> P......................__..__..._.....__............. <br /> __.___.._�_._.__.__.----__ <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 /> ............................................_.._ _ _ <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE = $35.00/hr $ <br /> _...___.............-__.........._..._..___.__._._.__.__ �.__ _..__..._.._._._____.._..__._. __ .........._............._.___.__ ....... <br /> TOTAL DUEp <br /> OFFICE USE ONLY <br /> M11�!II!!!I�I"slRims 1 WWI, ppGPs7 llflall!I�Ih1AAPl"� IIg19M l.: : �� �l�al'dP111 IBM EM11010 <br /> SWEEPS # COMP # L 0 C C 0 D E DIST CODE AMOUNT DUE AMOUNT Rr, D CHECK (CASH Rr,VD�Y DATE RECEIVED PERMIT # <br /> ..................__........� ....-.. _._... .._.._..........................,......_._.. _...__ <br /> iaci C�c�. <br /> ��I!!I�i���RR!•�R !R� �� n 111�R R R.•R!IRI!IIRRIIgIIRIRIRa IIIIIRII. ,!RRlli! IIRRRIRRRRIRIRRRIRRP!RIIR�!R!RIRRRRRRRRRIRRIR RIr�IIR�RRRIiRR�IRR,• IRRIRRRRRIgR�RII RIRRRUIRIRIIRII� RRRR�RRR!iRRRRRRIIRRRPRgRRRIR <br />