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JOAQUIN LOCAL HEALTH H D STRICT <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACILITY FEE = $100.00 <br />A <br />FACILITY/SITE NAME <br />FACILITY CONTACT NAME <br />1AIF <br />C <br />1 <br />Aq C-> Z (q "'6 <br />10 <br />S C <br />L <br />. <br />STREET ADDRESS SITE PHONE I WITH AREA CODE <br />I <br />T <br />Y <br />-- a 0� d� <br />CITY I STATE I 11P CODE �# of Tanks <br />i A0 /-7 IC4 1--5-- at Site <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />C applicable) <br />I <br />P <br />L <br />--- --------- ------ - �J-- Aq- <br />each TANK (see CA HEALTH & SAFETY CODE'Sec 25287 <br />I <br />MAILING ADDRESS APPLICANT PHONE I WIT" AREA CODE <br />C <br />d b0a /-c:a &n <br />I%.a <br />A <br />N <br />T <br />— <br />CITY STATE TYPE of APPLICATION <br />C) f CLOSURE, INSTALLATION, ETC. <br />FACILITY FEE = $100.00 <br />A <br />each SITE ADDRESS per YEAR <br />0 CLOSURE FEE z $10.00 each TANK I Tanks x $040.00 <br />S - <br />TOTAL ry <br />C <br />T <br />I <br />V <br />1986 1987" <br />TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x $80.00 <br />E TANK FEE = $50.00 each <br />TANK <br />F I Tanks x $50.00 <br />Ay u y by fee for <br />:ach 'year <br />1986 1987 1988 <br />I <br />1989 <br />C applicable) <br />I <br />--- <br />-- — <br />L STATE SURCHARGE = $56.00 <br />each TANK (see CA HEALTH & SAFETY CODE'Sec 25287 <br />for applicability) <br />T I Tanks 1 $56.00 <br />Y (enter ii6urii and year) <br />1986 <br />1987 <br />1988 <br />1983 <br />C PERMANENT CLOSURE (Removal or Closure -in-place) <br />L <br />PLAN CHECK (Installation or Repair) <br />0 CLOSURE FEE z $10.00 each TANK I Tanks x $040.00 <br />S - <br />U <br />R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x $80.00 <br />P <br />L <br />PLAN CHECK (Installation or Repair) <br />A <br />N <br />PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br />REPAIR <br />R TANK REPAIR FEE = $110.00 each TANK I Tanks x $110.00 <br />E------- ........ ..... <br />P <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 $10 FEE = $35.00/hr FEE $3,,.00/hr f <br />TOTAL DUE <br />OFFICE USE ONLY <br />................ <br />OWN., <br />SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVEDI PERMIT 9 <br />. ............ ........................ .................... ....... 1. Md . 11h . & - .. ...... . ... ---- . ...... ......... I ............... ......... <br />