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SAN 1YEIAQUIN LOCAL HEALTH DI*'RICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME — — +— FACILITY CONTACT NAME <br /> IA � <br /> L STREET AIDRESS SITE HONE tnrN AREA coon <br /> I <br /> Y CITY II ZIP CODE 1 of Tanks <br /> �b��_..— at Site — <br /> AA APPLICANT/BILLING NAME r APPLICANT CONTACT NAME <br /> P <br /> L _._. <br /> 1 MAILING ADDRESS _ — APPLICANT PHONE D MIM AREA con <br /> C <br /> T CITY �- --- STAT ZIP'CODE TYPE of APPLICATION <br /> _--_— ---- ��_--_--- CLORYIR. INETALLATIM, ETC. C O <br /> FACILITY FEE 1100,00 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A988 --- ----- <br /> 1986 _-198 --1 -�-�984� f <br /> v <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks x $50.00 --_- --1986_ 1987 — 1988 - - -1989 <br /> A (wltipTy I by fee for <br /> C each year applicable) $ <br /> L STATE SURCHARGE = 156.00 each TAW (see CA HEALTH i SAFETY CODE Sec 25187 for applicability) <br /> T 1 Tanks____ x 156.00 --1986 -- 1987 - 1988 1989 <br /> U <br /> Y (enter NA and year) - <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) -- <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK - 1 Tanks-'-_ x $90.00 f O <br /> S <br /> U <br /> P. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) pA YM 47 <br /> A __— ._ —� -- - CEIVED <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUOMISSION 1 <br /> REPAIR <br /> -------- -'EAI'1rIR <br /> R TANK REPAIR FEE = 1110.00 each TANK pER&T E3M1fNIEFJ�ASER L HEAL Tanks x $110.00 f <br /> A PIPING REPAIR/CLOSURE/REWYAL (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) (vhen applicable) (vhen applicable) <br /> FEE _ $30.001hrL_— FEE _ $35.00/hr FEE = 135.00/hr 1 <br /> 0--- <br /> TOTAL DUE <br /> OFFICE #SE 0A!r <br /> SWEEPS 1 can �.'� I'd,V,� ,«,«�TM"�"'��' <br /> r�� ( rH rY. a��A�k Ri 0 FY OA�E PECEIVEO PERMIT 1 <br /> —_ l _. <br /> 1)L lLi 6 mo w � Gi�I 1 d <br /> CSCE <br /> -ODE AMOUII i AnOUN( s <br /> ,awl, t��xMMqq yyi .. <br /> � +I:41W 4u h rngT'I V1m'1'If. :IrnV� tinMMi. : <br /> (-WW � NN C <br /> V � <br /> � �L�. -. .:� � w _ ... : : ' ..Aa.�J ���.d . �« n�l� at �:�7Ct�i�aP ate. . <br /> 7'111 110" <br />