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SAN*.wOAQUIN LOCAL HEALTH D+./TRICT <br /> _____ — UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> jf FACILITY/SITE NAME IA FACILITY CONTACT NAME <br /> C <br /> I <br /> L STREET ADDRESS a <br /> I <br /> Y fry <br /> $ITE PHONE WITH ARE cooE <br /> 1 <br /> C <br /> STAT .ZIP CODE f of Tanks ;7' <br /> _ G� at Site <br /> A APPLICANT/BILLIN6 NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> 1 MAILING ADDRESS <br /> C APPLICANT PHONE ! <br /> A WITH AREA caoE <br /> N CITY — — y_ Opp <br /> T STATE IIP'CODE TYPE of APPLICATION <br /> D UIOdwRE,%IWETALIATIOR. ETC. <br /> U✓ <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> kTTOTAL <br /> 1986 1987 1988 1989EE _ $50.00 each TANK <br /> -_---- ------s x (50.00 1986 1387ply ► by tee for <br /> year applrcabl , vv, f <br /> SURCNAR6E _ $5b.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability)- <br /> s x (56.00 198b1987 1988 1983 <br /> iiouot and year) <br /> C PEP,MANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE _ (90.00 each TANK f Tanks____ x (90.00 $ <br /> S <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 1 Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A - <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> P, TANK REPAIR FEE _ $110.00 each TANK ! Tanks x $110.00 f <br /> P __ ----- --- -- <br /> A PIPING REPAID./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/hrL IEE _ $35.00/hr — - FEE _ $35.00/hr $ <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> IN Id7Y'UmYA'. Jill 1.91 <br /> A =CHECK <br /> "10 <br /> COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNRCVD BY DATE RECEIVED PEP.MIT t <br /> �'. ti <br /> '%. <br />