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SAN JOAQU I N LOCAL HEALTH DISTRICT <br /> DERGROUND STORAGE TANK PROGRAM - FEE WORKS* PAYmEN <br /> *l FINCILITY/SITE NAME FACILITY CONTACT NAME <br /> C , ( r APR 17 1989 <br /> L STREET ADDRESS SITE PHONE k (with <br /> T Ok K 3 P ft�86ENTAL HEALTH <br /> nrni <br /> Y CITY G . STATE ZIP CODE 1 of TANK'S ES <br /> C lat Site <br /> A APPLICANT/BILLING NAE APPLICANT CONTACT NAME <br /> P 1-34 <br /> <S <br /> I MAILIN ADDRESS APPLIC T PHONE t (with Area Code) <br /> A �0 <br /> N CITY STATE ZIP CODE ITIPE of APPL ' <br /> T G (Closure, stallati , etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> I $ <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks x $50.00 1986 1987 1988 198.3 <br /> A (multiply-1-by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25281 for cability) <br /> I <br /> T I Tanks x $56.00 1986 1987 1988 1989 <br /> s Y (enter anount and year) <br /> v <br /> b <br /> C PERMANENT CLOSURE (Remova losure-in-plate) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK $ Tanks x $90.00 $ <br /> S <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks x $8 . # <br /> P PLAN CHECK (Installation or Repair) i <br /> L-- <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> R 30 — <br /> REPAIR <br /> E TANK REPAIR FEE = $110.00 each TANK <br /> P t Tanks x $110.00 $ <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to 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 $ �� <br /> OFFICE USE ONLY <br /> ,.: <br /> SWEEPS I COMP Y LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> a 5 f _ <br />