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SAN J, 11.11N LOCAL HEALTH DIS *CT <br /> tMoftf"o STORAGE TANK PROGRAM - FEE VORKSHEIT <br /> MANE-W!, kf: <br /> T rACILIIY/SITE NAME FACILITY CONTACT <br /> A <br /> C Z-X_z�qlsn ef <br /> SITE 'PHONE I WITH 4RffA CGIIII <br /> STREET ADDRESS q <br /> 6o I�jt <br /> _j;STAY;�1IP CODE I of tanks Y city at Site <br /> A APPLICANT/BILL TOO HOE APPLICANT CONTACT MANE <br /> P <br /> L APPLICANT PHONE I WITH AMA C601[ <br /> M�'ING AD SS g3 33 <br /> -CODE INGTALLATI <br /> A > i E o 17APPLICATION <br /> - <br /> N C 1p a". ETC. <br /> FACILITY FEE t 1100.00 each SITE ADDRESS Per YEAR —TOTAL <br /> A <br /> 19117 <br /> C <br /> V' <br /> E TANK FEE 2 150.00 each TANK <br /> F I Tanks z 150.00 1986 jjj <br /> A foul t ipri"I'by fle for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE - 156.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25297 for applicability) <br /> I <br /> T I Tanks 1 156.00 1386 1387 1988 1989 <br /> Y (enter ii6iAt and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE 1".00 each TANK <br /> S _ <br /> U ------- ........ <br /> P TEMPORARY CLOSURE (Only allowed one time for up to two Years) <br /> E_ <br /> TEMPORARY CLOSURE FEE - $80.00 each TANK T1 tanks...... 1 190-00 <br /> IPLAN CHECK (installation or Repair) <br /> L <br /> A, <br /> 0 PLAN CHECK FEE = 130.00 each SUBMISSIONIRESUEMISSION <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK I links------ 1 1[10-00 S <br /> E ------- ........ ........ ....... <br /> P___ *---------- <br /> A PIPING REPAIRICLOSUREIREMOVAL (fees are per hour, miftietua one hour to be paid on plan submittal) <br /> I <br /> I UNAUTHOILIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> l(when applicable) (when applicable!) (when applicable) <br /> FEE <br /> TOTAL DUE 1 <br /> OFFICE iff ONLY <br /> ASH 1,CVD BY DATE PCCEIVED PEPKIT I <br /> AMOUNT DUE AMOUNT Rr; "r v� <br /> j :2 i�-90`4 <br /> S116 srcr 1k 06 <br /> VE1P,EPS I COMP 1. LOC CT 01�1 CODE <br />