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5HN JUAQUIN LOCAL HEALTH DISTRICT <br /> RGROUND STORAGE TANK PROGRAM FEE NORKSHEE <br /> rF FACILITY//SITEE�NAME FACILITY CONTACT NAME p P�gD <br /> i s Sano Fe w 4&f& - c� on wer TemDe-'011 EG <br /> L SITE PHONE t "TM AMG1 Cmmm/"4 t t4-SOAV <br /> T r ala- 6/ to <br /> Y Clu- STAT ZIP CODE I 1 of Tanks NMEN V ES <br /> at Site Ety10.0 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P / <br /> P an - tyre . nC a i[f / i4M r" <br /> I MA ING ADDR S il �( / APPLICANT PHONE 1 wrTM AMA CMYw <br /> C ( rGi�/ �f 7' GCn / X7 / `.) 7 <br /> A <br /> N CITY STAT ZIP CODE TYPE of APPLICATION <br /> T (_.D x on a C� '�/ 7/ CLOSURE. tMeTAuATta+, ETC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A...--- -- -- - - — <br /> T 1986 1987 1988 1989 <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks _ x $50.00 1986 1987 1988 - 1989 — <br /> A (multiply 1 by fee for -- <br /> each year applicable) — 1 <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH f SAFETY CODE Sec 25287 for applicability) <br /> I <br /> 1 Tanks x $56.00 1986 1987 Z 1988 1989 <br /> Y (enter iiiiunt and year) _ <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — <br /> L - <br /> D CLOSURE FEE _ $90.00 each TANK t Tanks x $90.00 f n o0 <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 t Tanks x $80.00 f <br /> L PLAN CHECK (Installation or Repair) -_--- — <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBHISSION f <br /> _ REPAIR <br /> P• TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x 1110.00 f <br /> - - - <br /> P — <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I ---- -� _ <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE _ (35.00/hr FEE = $35. r -, f <br /> TOTAL DUE f <br /> OFFICE USE ONLY ����„ �. .� <br /> IAI��IGGI�VVGUGII9GGGIIIGIG41VIOMP mIGG�l�lt IGV@.IfJIGG1IG911G11 IGGGN9GImIIGGGIIV�IGIRVGBP�A�IINIGGI�IRI G�IGnVIIGGBNGIIGIgAVII�GIGi CI�III�IVIIGIIIIGI@IG II IGI�IGI@fiIIGflIGG�IVIGI�GIGI�I�IRI 'IG�WPAIIGgII�IGG <br /> SWEEPS 6 Ct LDC C11 ODE DIST CODE AHOUNT OUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVEO PERMIT 1 <br /> �� �IIGGI�III�GNI IftGIIGI�GIIGNIIIIPIIII�IIGIG GWII�IIGImGIIG G�IGVG�I��IIGDIG�GGIIGIII�IG!IGJGIVIIIG911�GII�IVGGI�1 IGGG�II����IGGI�II NI�IIMG�III�III�GG�I�I .IGIMII��I��IDIpIIIV <br />