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SAiyJOA�IIN LOCAL HEALTH L ;TR- T <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME _ FACILITY CONTACT NAME <br /> A <br /> C Ca�vr� C�h�+ arkr� Pcif Svn��h <br /> L STREET ADDRESS SITE PHONE t wrrw •mcg comm <br /> I /y/ iy. / �c�ro afo _ Yb /a <br /> Y CITY STAT TIP CODE t of Tanks <br /> —� SaO� at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P A,)e be;- Sa rnP <br /> L <br /> I MAILING ADDRESS _—! APPLICANT PHONE 1 w�rw aRca comm <br /> C _ -3 �L i fol/P e d�� - _ Y 3-iSb/ <br /> N CITY <br /> — STAT 2IP'CODf TYPE of APPLICATION <br /> --dccGIG/girrBnAO 9SFj/8 ewewe, nnTAuATrow. ere. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A .._..�--...--- --- <br /> -- — _ _._..__ <br /> C 1986 1987 1988 1989 <br /> T <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks f x 150.00 1986 1987 1988 1989 <br /> A (cultipty 1-by fee for _ <br /> C each year applicable) — — S� p 1 LgQ <br /> I — <br /> L STATE SURCHARGE o 156.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> I -- <br /> T 1 Tanksx $56.00 1986 1987 1988 1989 <br /> Y (enter ;count and year) — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK I Tanks x 190.00 $ <br /> S <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E TEMPORARY CLOSURE FEE _ $80.00 each TANK t Tanks x $00.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L — <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUCMISSION f <br /> REPAIR - <br /> _----- — <br /> P. TANK REPAIR FEE = 1110.00 each TANKt Tanks x 1110.00 f <br /> - - <br /> E — --- _ ..._-._.... <br /> __ — <br /> p —_--- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> ------ <br /> ----- --. — <br /> R UNAUTHORIZED RELEASE EVALUATION iCONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE -- 130.00/hrL _v— FEE _ (35.00/hrL �— FEE = t35.00/hr -- f <br /> TOTAL DUE Is <br /> OFFICE USE ONLY <br /> II ""''PS ICO P�Ip�LOCI CO OE DIST O�OEI�AMOIUNTI OUE� A�OUNT�RC�VQ� CHECK 1/CASH RCVDmDY GATE—RECEIVED PEFMmfT�1�� <br /> �L136 C/viC/y o 3a3 S v� <br /> !I,�GImi�. <br />