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SAFE OAQUIN LOCAL HEALTH Ded`TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FFACILITY/SITE NAME <br /> IA - - - FACILITY CONTACT NAME ' <br /> I <br /> L STREET ADDRESS SITE PHONE A NITN Am[A c00[ <br /> .?S Cbl d.� _ <br /> T---`f-- _-�_ Sa 99 -3750 <br /> Y CITY STATE ZIP CODE 1 of Tanks <br /> --� - at Site <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILINGADDRESSAPPLICANT P ONE 1 M(TN Am[A cao[ <br /> p .. —f f—� -C�' '— _Sv _ _z — a <br /> N CITY STA E / ]ftp CO/DE/ APPLICATION <br /> -T.,.-_--- Rl —�(=!p 3__—f1 GIORUR INSTALLATION, [TC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR — - TOTAL <br /> A...._.----_._.........-..._.- _ - — <br /> C 1986 19.7 1988 1989 <br /> T --. <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks x $50.00 1986 1987 1988 1989 <br /> A (multipiy 1-by fee for <br /> Ieach year applicable) <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks 5' % 156.00 1986 1987 1988 1989 <br /> Y (enter 5i unt and year) - ----E <br /> - — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — - — <br /> L -------- — --- --- ......— -- <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks $90.00 f <br /> S x I <br /> U ..--- ---_--_--—--- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks x $80.00 f <br /> PPLAN CHECK (Installation or Repair) — — -- <br /> L <br /> Al <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUDNISSION $ <br /> -. .REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks --- x (110_00— - <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 jNST <br /> ORUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr FEE _ $35.00/hr FEE = $35.00/hr $ <br /> TOTAL DUE f <br /> OFFICE USE ONLYfdr I�`� y)/arj <br /> uPPI�P.Q" FN91PAI�1�!gl".m� RfP,mIPIp��9�l AKIN �� i:,, "i PiIP"Cn"r,it.��?h1fl�"1C1)I1Mk�Gq�!!�Fl�l�i� a�1!.�GIk11Pf"1f��T.1111, IiP4:1i11ftl� 9RBRS11SIRRRIm. GIL�.�i!��I151:II. IGP�; <br /> ,KEEPS A CONP Aj;0QT1 <br /> LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHEC /CASH RCVD BY DATE RECEIVED PERMIT A <br /> ... . ._..�',u'Ao011�1�� a � � tfl .911I��NIGfCI ��RII�IIIC!��III��I�CIf� iIlPlil � l��@9fltllltll�l�t II�II��NU9�I� .� �II@�111194 �INI4PIE111�IRIN�I�@U�ltla� <br /> 71 :41 3i ; V 1,,185 Cytti��(Yd r <br />