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SAN >`l1QUIN LOCAL HEALTH DIS,...�ICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> IF�FACILITY/SITE NAME ---- - -- - - -- '---- FACILITY CONTACT NAME <br /> 1AuTpp�IFYicQlc�c>N��.sl�j_�°_-_-- <br /> L STREET ADDRESS SITE PHONE I WITH AREA COUE <br /> T <br /> Y CITY STATE ZIP CODE I of Tanks <br /> at Site �FGL.)b Cz� <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P �/ <br /> P <br /> 141f FJL t/ /Y� CT-�__ Se2!!.(.GQy-�d/S� L�►�57 /CL11YE fn -- ✓!C Nc <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> T <br /> N CITY STATE ZIP CODE TYPE of APPLICATION �J�/ A� <br /> T - CQ /�� CLORURE• INiTALEATION� ETC. 1�..0/•`DV/I'L- <br /> fFACILITY FEE _ $IO0.00 each SITE ADDRESS per YEAR / �//- -- - TOTAL <br /> IA 7 <br /> 1 -- � _1386---- -_- 138 -1388 �- 1389- - f <br /> IE TANK FEE _ $50.00 each TA14K li- <br /> F I Tanks z (50.00 1986 1987 1988 1989 <br /> A (multiply I_by fee for <br /> C each year applicable) <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFI T----ETY`CODE Set 25287 for applicability) <br /> 1 — <br /> T 1 Tanks z 156.00 1986 1387 1388 1983 <br /> Y (enter eiouit and year) <br /> C PERMANENT CLOSURE (Remoyal or Closure-in-place) - - - <br /> 0 CLOSURE FEE _ $90.00 each TANK - t Tanks_ 2 z <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, t Tanks z $80.00 f <br /> ELANCHM(Installation or Repair).FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK I Tanksz $110.00 S <br /> E ---- -- - -- -- - '-- ----- —- - <br /> F - -- --- - _- - - <br /> A PIPING P.EPAIR/CLOSURE/P.EMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I - -------- — <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION -- --SAMPLING INSPECTIOfla �fo� <br /> (when applicable) (when applicable) (when applicable 9rR"1A 81 <br /> FEE = $30.00/hr _ - FEE _ $35.00/hr FEE _ $35.00/hr SSYO f <br /> TOTAL DUE f <br /> OFFICE USE ONLY d 17 5 CtD <br /> ' 19P�99111.�Jfli�l!MIflflIIGB-'Ofl09V14fl9--III-BflVPi9"I@flVfllflli!IIflflIN!Ilul@mlflflllV--lfll!flIIIMIflVIIflflIflIPflB�:7�I��1011flflfl111flIIGlfflflllfllflllllV�IfIIOITIIDI�u.fl�flll&9�1' 90V�V'I <br /> �^u� Illd • . li .I9 i I I 11991fl1 II �91i ill) Lt,!IGI I I I 111197 9 I -'"--'- <br /> SWEEPS t COMP I LDC: CODE DIST CODE AMOUNT DUE AMOUNT P.CVD CHECK. 1/CASH �RRCYD BY DATE RECEIVED PERMIT tfl�rl <br /> Efi': 9t FEE '.1� �I� : fl 6.1.ifl9.SID.L.flL,1.1.fl.lmf.1.iflfl..9fl.1.fl'l'.... flJfllfll.l��lll99..,...flflfll�IflNflV9.E 91,flPCA9�lfl!., ! i G!�Slll�k�!@�RIGflls01. <br />