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�✓ <br /> SAN NOW LOCAL HEALTH DISTRICT <br /> ll • FEE WORKSHEET <br /> UNDERGROUND STORAGE TANK PROGRAM — <br /> iFIFACILItY/SITE NAME - - - FACILITY CONTACT NAME <br /> �---- - - <br /> C SHIFLL S�I2V1Gi; STATIo�I po}-I J . T/�kAhIASJ-� <br /> I - --- - RH !A COD! <br /> STREET ADDRESS � �. 11 . SITE PHONE 1w2�� <br /> STATE ZIP CODE7'atoS�iltaer <br /> ks <br /> Y CITY c)-r -- --- -- --CA 1752G� THI'1=e <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P �S€2T N ►- g�oG. J EFF TA%�� <br /> L - ----- - --- -- — .�.-- <br /> I MAILING ADDRESS APPLICANT PHONE 1 HIrH AREA coot <br /> c i3 fl I-los. -� E /.�/•� �Z►I � - 003 <br /> N CITY / 1 To STATE ZIP'CODE TYPE of APPLICATION T I <br /> T ✓� ���N - _ ___'.-�( � cLaeuRc, IH/rALLAr1oH, lrc.Iht.jT4L� b <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR - TOTAL <br /> 1 986 -_ 1987 1988 1989 f <br /> V <br /> — N -- <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks_ x 150,00 - 1986 1987 1988 1989 <br /> A I ultiply ( by (ee for - <br /> C each year applicable) <br /> 1 — <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks x $56,00 1986 1987 1988 1989 <br /> (enter aeount and year) <br /> PERMANENT CLO (Renu II or Closure-in-place) -- ---- <br /> CLOSU ---- D h TANK — I Tanks_ 3_ x (90.00 f 270. 00 <br /> TEMPOP,ARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORAP,Y CLOSURE FEE _ '$80._00 each TANY, �1 Tanks _____ x t80.Q0� f <br /> P PLAN CHECK (Installation or Repair) — <br /> I�N PLAN CHECK FEE = 130.00 each'SUBMISSION/RESUCMISSION f 30'o0 <br /> I REPAIR - - <br /> F. TANK REPAIR FEE _ $110.00 each TANK ----- I Tanks _ x $110,00 $ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, ainixuy'one hour to be paid. on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATIONCONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr - FEE = S35.00/hr j FEE $35.00/hr f <br /> — - -- --- TOTAL DUE f Gil <br /> OFFICE USE OBZY <br /> M.QlMQOMM001Q MQQQMPM9MQW9MUM QQN M�1;Q�19lQINNIP411TO 0TIFE,QQ."!sQUQGQuMIR 01191!QQQ"RN.IM30Q101.IQQ€7Z'10 .r?�QQ UT5.lfQQCQP9QII�QP QQQQI�QfQ�IQ1�1G�QAQQ0.�j <br /> SWEEPS I COMP I LOC CODE GIST rnnE AMOUIIT DUE AMOUNT Rr,VD CHECK I/CASH 1 RCVD BY DATE RECEIVED PERMIT t <br /> �j---. --- -----''------- ,�- ./.mac ------- -�-, - - 4'-- <br /> DmMrP7Mmlmmmm),3 mP°T�Irimltr ml)ImamlMppliRlgl,)I gip,m Ilam mmrrmtlrldrmmmrm1fl !raMln.� mlm t�mf�otmQ ml�MmfllmmmgGl$mmmMh <br />