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SAA Cf©AQUIN LOCAL HEALTH ATRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> CC:t NU GJ1 f'S n lc <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> I c 2e9- <br /> T <br /> Y CITYS�TAat Site jE IIP CODE I of Tanks <br /> ,,��" -21 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> I MAILING ADDRESST - - APPLICANT PHONE I WITH AREA COD! <br /> > - 2000 <br /> N CITY [/� _ STATE IIP CODE PLICATION <br /> ,.r ����...---._......____.-.__........__»..»._.,...___��� Ct06URE, INSTALLATION, ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1983 <br /> T .......... <br /> I $ <br /> E TANK FEE _ $50.00 each TANK <br /> m -- 1-by fee <br /> ........... .._. o . <br /> ,_........ ....».._...,.»_.__....,_......-....._......... ..- . .....--.._.__. .__...._......_....».._.,.»._ .»...._......_......_.........-......_..- ---—_____.»._._..._ _-__ -............... <br /> _.. <br /> F # Tanks I x $50.007 1986., 1987 1988 1989 <br /> A ( u <br /> r -_.. —___..____. _._. ___ --- -- - _._ _ » __-__ _ _ ____ ... <br /> CC each year applicable) 5-0 So <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> ............_... <br /> T I Tanks_I_ x $56.007 1986 19G7 1988 1989 <br /> Y (enter mount and year) <br /> �h f 56 <br /> ---..........._._...................... <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> O CLOSURE FEE = $90,00 each TANK # Tanksx $90.00 f '� <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> - <br /> TEMPORARY CLOSURE FEE = $30.00 each TANK # Tanks_ _ x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L....»»._.. _.__................................_._..._._.. _____ _. _ .». ._ ..._..._ _ _ _ ..__ .... _,._..____--_....._------._......._.....--- — <br /> A <br /> IN PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION $ <br /> REPAIR _ <br /> R, TANK REPAIR FEE = $110.00 each TANK I Tanks _ x $110.00 f <br /> E _____ <br /> _..... <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I..........__....._.___.._.._.__...._..._._____..-._.......__.._.___.__...__....._.._. ._..__.__._._--.---..._....---__-_- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.00' FEE - $311S FEE _ $3S.001hr� f <br /> ___.___ _. _ _...........--...-----...__ <br /> _......_...._..........._.._........._.........._ _.._._ _.._ TOTAL DUE # {0-6 <br /> OFFICE USE ONLY <br /> 111!11111.1011 1111llnl!fll1 TRIP!111'I1IFIRi�l�i A IMP MIN !!li,�•'0�li�I�II�C�1 _liil!li��lliil�Il':!i?iii;liliil!�IilL�ll11���i�!Illllilli:l�l[i��!��!p III�<�I!!�'ii!!�IQI�6��illi?I��IIII111 <br /> ._ .. DUE AMOUNT RCYD ^PCHECK r,ASH RCVO BY DATE RECEIVED PERMIT # � <br /> SWEEPS # .. COMP # LOC CODE DIST BODE AMOUNT __.. . .......... ...............». . _. <br /> A��'Rll� [ k '`/ sfl6 i `1 <br /> ��;I!II�� �pil►u'u ' I t�111!ll��''iI�! il��illlllllnllli��R��l!! !GI!!!4;1!Ifl�lil �(iln�1!�!;ill)! i!1�!!I!!!Gillll�Illl�!illllill� G� ,P�I� � II�(I ,i IfN�InIVI�IQ�nil�,lll!9!n!� IIII�BItl��lli�,4!i ��VI111�111IIIQ! 11IIgln� <br /> 3 qe" 60-0 <br />