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SAN JUAUUa1v a .• ^� • • _. _ <br /> UNMROUND STORAGE TANK PROGRAM - FEE WORKSHEET — <br /> FACILITY/SITE NAME FACILITY CONTA�AME <br /> C <br /> T <br /> SITE PHONE 1 wl fN •mm. co ■ <br /> L STREET ADDRESS�� <br /> l - <br /> SJAT IIP CODE 1 al Tanks <br /> Y CITY 6 ---- <br /> IVGaO ((,,�• at Site <br /> _t APPLICANT CONTACT NAME <br /> A APPLICANilBILLIN6 NAME /V1 i' <br /> P 44 v <br /> L � ( f -- APPLICANT PHONE 1 vrr" aReA cane <br /> I MAILING ADDRESS ^c u/ ✓ j� T �� aOS - 5���" 5��� <br /> C �J / LJ �T — <br /> N CITY � (r �'A SSE c,oiuni.Aio:i�A���NaN. =rc. <br /> T �'74 e-�O h ff�� -- —� <br /> --�— — — TOTAL <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR _ --- -_-----__-____ ----------- <br /> -- 1986 1981 1988 1983 _ —,-- <br /> E TANK FEE + $50.00 each TANK _ <br /> 1986 1988 1983 <br /> F I Tanks x $50.00 1381 $ �Z o o <br /> A (multiply I by fee for <br /> C each year applicable) --- <br /> 1 - <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 252117 for applicability <br /> I19116 1987 1988 1983 <br /> T 1 Tanks )_ x $56.00 — — <br /> Y (enter amo nt and year) $ 7 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) M� — ------ <br /> 1 <br /> CLOSURE FEE = 190.00 each TANK _. <br /> R TEMPORARY CLOSURE (Only allowed one time for up q <br /> E --- ENS �I �F�Tanks x $80.09 $ <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK <br /> _— <br /> F a� — <br /> P PLAN CHECK (Installation or Repair) -------- --- <br /> A t <br /> H PLAN CHECK FEE = 110.00 each SUBMISSION/RESUBMISSION --- <br /> REPAIR <br /> - <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> E — <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittaU ------- <br /> I SAMPLING IIISPECTION <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION (when applicable) <br /> lvhen applicable) (when applicable) _ _-_ _ <br /> FEE = f15.001hr $ <br /> FEE = 110.00/hrL— FEE = 135.00lhr�---- --------�--__'-- ` a p-- <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> TI�°l4 0.1"ur IltJWW1. I l,19N 11MIN II�I�G 99fd L9Gf�19a T�ra1CA:, <br /> I SWEEPS 1 COMP I LOC CODE DIST CODE AMOUIIT DUE AMOUNT Rf,VO CHECK IICASH RCVD BY DATE RECEIVED PERMIT $ <br /> 3i <br /> 3a,mm22I� a�--- Q L m� <br /> . J1 " <br /> ii .9 .l, i.�.1 <br />