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'�' I F FAtItITY/SITE NAME <br />l STREEi.ADORESS , <br />CITY p <br />APPLICANT/BILLING NAME <br />SAN 1AGUIN LOCAL HEALTH DIF—RICT <br />'onnERGROUND STORAGE TANK PROGRAM - FEE NORKSHE6.mo/ - <br />-� TFACILITY CONTACT NAME <br />l.SfTE PHONE IMIT" "t "t" °°°t <br />1T IIP CODE1 of Tanks <br />at Site <br />TAPPLICANT CONTACT MANE <br />~"� `•- --�_�' -- _ APPLICANT PHONE 1 MIT" ANCA Cott <br />LING AORRESS <br />�i— (A 6A— 33 3 <br />_. <br />y STAT IIP'CODE TYPE of APPLICATION <br />,LosUltt. INtTALLATION. CTC. <br />C <br />—_—_.—------_ <br />—_..------ TOTAL <br />0 <br />FACILITY FEE = 1100.00 each <br />SITE ADDRESS per YEAR <br />A <br />---- -- <br />1386E1987 1988 1983 - <br />T <br />I <br />TEMPORARY CLOSURE (Only allowed one time for up to two yeatl) <br />- 1 <br />— <br />TEMPORARY CLOSURE FEE = 180.00 each TANK <br />E <br />F <br />A <br />TANK FEE = 150.00 each TANK _ -------- <br />1 Tanksx 150.00 1986 1981 1988 1989 - <br />---- - <br />(multiply_ 1 by lee for 1 <br />C <br />each year applicable) <br />L <br />STATE SURCHARGE - 156.00 <br />each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br />T <br />1 156.00 <br />1986 <br />1987 <br />1988 <br />Y <br />(enter amount and year) <br />- <br />1 <br />C <br />PERMANENT CLOSURE (Removal or Closure -in-place) <br />- - -- <br />0 <br />—�--- <br />CLOSURE FEE = 130.00 each TANK0.00 - <br />1 Tanks a z 19 <br />It <br />S--— <br />U- <br />R <br />TEMPORARY CLOSURE (Only allowed one time for up to two yeatl) <br />TEMPORARY CLOSURE FEE = 180.00 each TANK <br />1 Tanksz 180.00 <br />PLAN CHECK (Installation or Repair) <br />PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION 1 <br />REPAIR <br />TANK REPAIR FEE = 1110.00 each TANK I Tanks x 1110.00 1 <br />PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum One hour to be paid on plan submittal) <br />UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION it ECTION SAMPLiNO INSPECTION <br />(when applicable) (when applicable) (when applicable) <br />FEE = 130.00/hr1 _ - --A FEE = 135.00/hrL -- FEE _135.00 /hr 1 <br />TOTAL DUE 1 <br />OFFICE USE ONLY <br />;WEEPS 1 COM` I I <br />LOC CODEIDIST CODEI AMOUNT DUE I AMOUNT VD ECK11CASH RFVD BY DATE RECEIVED PERMIT <br />I h4 D 0 `,. �.... mnim mmm�mnl�AimCIt1AA <br />Oji <br />