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SAN J - QUIN LOCAL HEALTH DIS' 'CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET ../ <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> 1 <br /> Air Arl Spa kMer Wlkerri-J <br /> L STREET ADDRES�,,, SITE PHONE N (with Area Code) <br /> I - r� Roaa( 2oq- -o 0 <br /> I <br /> Y CITY STATE ZIP CODE Y of TANKS P E " Eie D <br /> oC M e� s at Site E 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P -44 S �r lac <br /> L 43� <br /> I MAILING ADDRESS APPLICANT PHONE $ (with AreHFA( <br /> A 133 N. Ad-44 Ze9 - 3! -duo rFs <br /> N CITY STATE ZIP CODE TYPE of APPLICATION SO;J Sa+. Xn M <br /> 205— (Closure, Installation, etc.) <br /> f 70 <br /> .t <br /> i6 <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 f <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks x $50.00 1986 1987 1,388 1939 <br /> A (multipiy t-by fee for <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH d SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> T I Tanks z $56.00 1986 i981 1988 1989 <br /> Y (enter aoount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK $ Tanks z $30.00 f <br /> S - <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 $ Tanks z $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L — <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> R REPAIR <br /> E TANK REPAIR FEE = $110.00 each TANK $ Tanks x $110.00 f <br /> P -- <br /> A <br /> 1 PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R l <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING r <br /> (when applicable) INSPECTION INSPECTION / <br /> FEE = $30.00/hr FEE = $35.00/hr FEE = $35.00/hr Is <br /> TOTAL DUE Is oa <br /> OMe-FFICE USE ONLY <br /> SWEEPS I COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCV CH[17C ASH RCVD BY DATE RECEIVED PERMIT 17 <br /> ori 3 2y �,ob 3S" �/63s C# <br /> ur.. -n ,.;�r»i nr..y ✓ _ �P <br /> 1%W <br />