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SAN .l"Tc AQUIN LOCAL HEALTH DISR!21CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F <br /> FACILITY/SITE NAME — FACILITY CONTACT NAME <br /> C Unocal Bulk Plant #0788 Chuck Bryant <br /> L STREET ADDRESS <br /> SITE PHONE 1 WITH 4111114% Come <br /> 18203 W Business Loop 205 ( 209 ) 836-0376 <br /> �r STAT IIP CODE 1 of Tanks <br /> Y CTiacy CA. 95378 at Site 5 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P BASSETT CONSTRUCTION INC. REX H. BASSETT <br /> L -- -- — APPLICANT PHONE 1 WITH amen come <br /> 1 MAILING ADDRESS <br /> C 7730 Greenridge Way ( 916) _967-7424 <br /> N C Y , ——STAT jIP'COOE APPLICATION <br /> T Y Oaks, CA. 9 628 c�otuePLICATIONINSTALLATION, ere. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1981 1988 1989 <br /> r <br /> I — _ — <br /> I — <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks _ _ x 150.00 1986 1981 1988 1989 <br /> A (multiply I by fee for $ <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks 1 156.00 1986 1981 1988 1989 -- <br /> Y (enter ii6uit and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — <br /> L 1 Tanks_ x 190.00 $ 90.00 <br /> 0 CLOSURE FEE • $90.00 each TANK — �1-� <br /> S- <br /> U — —' <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) — <br /> E TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks,=,,- 180.00 1 <br /> T ,-__-- - <br /> PPLAN CHECK (Installation or Repair) <br /> L - <br /> A $ 30_00 <br /> M PLAN CHECK FEE _ $30.00 each SUBMISSION/kESUBMIS5I0ti — — _-- <br /> REPAIR <br /> TANK REPAIR FEE _ $110.00 each TANK 1 Tanks------ x (110.00 <br /> F. <br /> n — <br /> E -- --- --- ----- — <br /> F <br /> A PIPING REPAIR/CLOSUREIREMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> --------- — <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IIISPECTION <br /> (when applicable) when applicable) <br /> FEE = 130.00/hr FEE _ f35.00lhr FEE _ $35.00lhr <br /> TO.TAL DUE $ 120.00 <br /> OFFICE USE ONLY mum <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/LASH RCVD BY DATE RECEIVED =PERNIT <br /> n � <br />