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SAN % , AQLIIN LOCAL HEALTH Dl,.ARICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ---- -- - - — --- ------ --- -- --..._..-------•----- - - <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> 1A — ^ ARCO PAQLLTY # 071o0 <br /> C DAVID H(LDt%NESRAND <br /> 1 - SITE PHONE Y WITH AREA CODE <br /> I STREET ADORESS 226 50Gkh6R-nV-6E LANE (20q) 366- 18(03 <br /> Y CITY STATE 11P CODE 1 of Tanks FHP-E0 �3) <br /> Lo D= �cA 9g2a}O at Site -- <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME 9A1ZGHA056fJ E3tJGR$ <br /> P I3AR-GHAAISE IJ 6M6(N6EIz-5 ?SILL MAR1 WGH <br /> L --- -- ------- --._._........_.-------- ------------ -- <br /> 1 NAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> 0 4612- Ro56V(LLe RoAv suif'a 10_3 (41(o) 348- 3057 <br /> A— <br /> H <br /> -- —--— -- -...—.. _ -- —— 'C <br /> -- <br /> H CITY STAT 7IP'CODE ITYPE of APPLICATION <br /> NORTH 14t6H LAUDS GA X15(,(00 cLOsuAE INSTALLATION, ETC. REMOVAL <br /> IA FACILITY FEE = $100_00 each SITE ADDRESS per YEAR TOTAL <br /> 1 -�`1986 �_--1987 --1988--1 —1989-� s--_-------- __ <br /> v 1j- <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks z $50,00 1986 1987 1988 1989 <br /> A (multipTy( by fee for - -— <br /> I each year applicable) -- PAYMENT <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH G SAFETY CODE Sec 25287 for applicability <br /> l - --•------- ---- <br /> T 1 Tanks x $56.00 1986 1917 1988E <br /> 1989 NO V 1 1990 <br /> Y (enter iiount and year) -- --• --•------ -- ---- ` - <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) - - -- -- PENMIItKVICES <br /> L --- --- - ----- -- --- - O — — --— <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> S-- 1 Tanks _ z $,0.00 f 270- 00 <br /> — �. - -- <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 /> A - <br /> tl PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f Aj0,00 <br /> REPAIR <br /> P, TANK, REPAIR FEE _ $110.00 each TANK I Tanks x $110.00 f <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/hrr FEE = 535,00/hr $ <br /> TOTAL DUE S 300 . 00 <br /> OFFICE USE ONLY <br /> 1;1�!mlPp"� .�!911�Ip111U4!IHI&�.m19!I�l�l@'14�99fu?!�!igNP.9'IqG!��!JRl�lil'IfialIII1GIIClci,N�lflB!lil!i.�h1Hil.":!!llV��In9BdIfln191�VNf;Vll91"ll'wl�':I�ullliNl�"IIWIIG!IIi11Vl�il!IIICIIInIC!1!i!uf�illlf.f9�1n1111'�9W!Iflfil!ICI!C!N1!INMp 99�'�!!PLmI1V!VIIIG?ilGtil�!11Cu!j' <br /> I! SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH ROD BY DATE RECEIVED PERMIT t <br /> _. <br /> a !gl -- <br /> 1i TAI hl � !IGI�4111 111s j11F,ia"ll� � . „1111!111! niWNillalgl idmol 0111MUIiR 111TEli 1 O/ 'VF. P!IIIIPgIV!@Wlfiih9l�RR@IR�h'8119111.7 <br />