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SANOOAQUIN LOCAL HEALTH DCRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME <br /> A T�' FACILITY CONTACT NAME <br /> �r <br /> I�o�ert� ting; n ex r v q cpvtis7_ CO. to De-aril C ,TfaC-l„v 'S <br /> L STREET ADDRESS z9` SITE PHONE 1 WITH AREA COO[ <br /> Y CITY r I' �� T 1E ZIP CODE I of Tanks <br /> — LIvC:i Liv at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L.... _ —.__._�1(.�t� l Pte `?_—�S 9P-- --_ _ <br /> i MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> C <br /> A _ <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, IRSTALLATIDN, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A..._........— __ _ ...._...—--E <br /> T 1986 — 1987 1988— --1989 — f <br /> f <br /> E TANK FEE _ $50.00 each TANK <br /> _ <br /> A (multiplF 1 Tanks __ _ x $50.00 by fee for 1986 — 1387 1988 11f�IgY ENT <br /> _ <br /> y 1 — -- RE <br /> C each year applicable) IVED f <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH d SAFETY CODE Sec 25287 for�q�r, r 1 <br /> T 1 Tanks x $56.00 1986 1981 1988 _ 1983 <br /> ---- <br /> Y (enter amount and year) --••- ----- ----•— € A"CFiE'j{[ <br /> _ - PERMIT <br /> C PERMANENT CLOSURE Remova or Closure-in-place) ----` <br /> L - <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanks-A x 190.00 f ( � <br /> S — <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 /> fl PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> — ---- — .—_ ---- —..—.........._... <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks______ z $110.00 f —� — <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 _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr f <br /> TOTAL DUE $ l C <br /> OFFICE USE ONLY <br /> G IGG'�IG1�8��IIGG1G11!OIGMIIiG�G��h111949�,�l�limi 1GIIGq"�!IVIGGGSa'�"VGG1!�Gfi!IG���1�11G1i1mI,,GpGIG11�'i191�I��iIIM 11LG 1,11,III�I�IGIGTG11igImTl!II�G!!IIII!P„L,,uGI1tlIV CI6,�V111�9CV�IN,iIIIG�IC!I��II!II�G@!IGG!IiGGIIVI!GG1,16!Im!��1GG! <br /> I rSIWEEPS II COMP t I ILOC(CODEP I f � • I'I P ip � i�i'pp 7, I'i'' ' III i� <br /> DIST CODE AMOUNT DUE AMOUNT RC,VD CHECK 1/CASH RCVD BY DATE P,ECEIVED PERMIT I <br /> ' p_���1 9b•� �D• � I� � �� 5-1 l - o ln� <br /> PIMC,�I,., �� III Ipplh '�IRI!IIGGI�1h1VG I!!hIIGG�!!IGGGIif IG!II!III@II@�I�IGI�III!!IGGG!p�!I �iG iINVGl9!GIIIIG�IIIGI!il figPilG gIV.GG GGI!Al l�q IGGGRG! 1191GQGGGII,m1111�1�1611111�flII I GGIIVG9L.,GIGIAUE11!1 X01 <br />