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SANtiOAQUIN LOCAL HEALTH D"ARICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F(FACILITY/SITE NAME — — ^— — FACILITY CONTACT NAME <br /> pl RV*r 71�vc.� v,Ut� GJr �.9h� <br /> C <br /> I <br /> ISTREET RESS S E HONE�I YITN AREA CoOE <br /> T /`/�D �rD eG J ��/- �i�o0 <br /> Y CITY CCT T TIP CODE I of Tanks <br /> lofnx Ll1on -- ___-- @ 95& -_ <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> [ MAIL G ADDRESS AP LICANT PHI E t wlro AREA eooE <br /> Alf 3�c1 <br /> N CI /, —1yeE TYPE of APPLICATION <br /> T �n//I, Y/AC/J/ J ,/ CLORURE, INSTALLATION• ETC. �•�O <br /> A FACILITY FEE _ $100_00 each SITE ADDRESS per YEAR TOTAL <br /> V1986 —^1987 _ 1988 _ 1989 <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks —z 150.00 — 1986 1987 _ 1988 1989 - <br /> A (multiply 1-by fee for — <br /> C each year applicable) - f <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 4 SAFETY CODE Sec 25287 for applicability) <br /> I - — <br /> T 1 Tanks z 156.00 1986 1987 1988 1989 <br /> Y (enter iiouit and year)) <br /> S <br /> C PERMANENT CLOSUR (Removal r Closure-in-place) <br /> — <br /> 0 CLOSURE FEE _ (90.00 each TANK 1 Tanks-_,;Q_ z 190.00 <br /> t <br /> S �.— <br /> U .— __ I� <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E TEMPORARY CLOSURE FEE = $80.00 each TANK_ t TanksY z $90.00 - f <br /> P PLAN CHECK (Installation or Repair) — ^— <br /> �1n L.... __------ — -- ------ — --------- -- - <br /> A <br /> M PLAN CHECK FEE = $30.00 each SUBMISSIOI(/RESUCHISSION f <br /> REPAIR—_-- -----_. __ —_ <br /> P. TANK REPAIR FEE _ $110.00 each TANKt Tanks z (110.00 f <br /> - -- - <br /> E -- <br /> F <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <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 = $35.00/hr $ <br /> j TOTAL DUE IS <br /> OFFICE USE ONLY <br /> ,!I!'@,QIP,V�V!qV@VI�IV@@PV!Pll!q@VAIVVI�llglq'pV@!I�VVP�gNVO �NVG4�VVCUVi�I'VV@V@@i1VVV@!I'VII@@@@il.'!!�@P�N@V@V@IVV!@gIP�IVG ;�IVG�fI!VIII@�11i@IVIVII!@1@IIIIIIV^J!�IuVliiiilf 'Ju�1�!!MV!iGll@VIIV1IC!��N@ VIVf�I;q!VlgVl@I!IIVi�:I@'�IiflQP:U�� <br /> SWEEPS t COMP 1 LOC CODE 01ST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD DY GATE RECEIVED PERMIT 1 <br /> ,QVC@IIVViU!I@@V@,lii@_ :dll@IV!ViIVIIII�V@Vllli@@@'IP.GII�i�III'I@111�VI111111i11VIII@IUJVIPIVIIII@VVIIPIIIIII@IIV �:@@�IIfIVIVP1111016SII@�I�IIIIIIIII@N1@IIgVVIIV@I@I 11100 gl,1111V101@V05i�i <br /> 1 ��� <br />