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S DAQUIN LOCAL HEALTHRIOT <br /> £RGROUND STORAGE TANK PROGRAM - FEE IdORkS t <br /> F FACILITYISITE NAME FACILITY CONTACT NAME y <br /> L STREET ADDRESS / SI E PHONE I (witf�rea Cede) <br /> T <br /> Y CITY r STATE IIP CODE I of TANK'S r <br /> a t Site <br /> A APPLICANTIBILLi G'NAME APPLICANT CONTACT NAME <br /> P /7 S;14 <br /> P , - <br /> L <br /> I MAILING ADDRESS APPLICAI ,JONE i (with Area Code) <br /> C ro, <br /> A STATE I E CODE TYPE of APPLICATION <br /> N CITY <br /> t+ti PwT (Closure, Installation, etc.) <br /> FACILITY "EE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> t, 1586 , 1987 1998 1989 <br /> T - <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks1 x $50,00 1986 1981 1988 <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 b SAFETY CODE Sec 25287 for applicability) <br /> I - <br /> T I Tanks__(__ x $56.00 1986 1987 11388 1939 <br /> Y (enter aaount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> D CLOSURE FEE = $90.00 each TANK I Tanks----- x $90.00 <br /> 5 <br /> U <br /> i TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks----- x $80.00 $ J <br /> P PLAN CHECK (Installation or Repair) 4 <br /> L — <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK I Tanks----- x $110.00 ; <br /> A <br /> [ PIPING REPAIRICLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = $30.00/hr FEE _ $35.001hr FEE _ <br /> TOTAL DUE $ �' ,nJ <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK IICASH RCVD BY DATE RECEIVED PERMIT I <br /> .. . ...: -,. .: r 6 ....i:. :,,,; ,.. •,•r C„•r. 1. , _:.. '-{.. .l. <br />