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SAN&AQUIN LOCAL HEALTH D A RIOT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> IF FACILITY/SITE NAME - _ FACILITY CONTACT NAME <br /> _�L)er� 1 TA Cy�mMJ,�r e61-(t&& � ,(?r ILt. r4Q 't&67 <br /> I S�4 Tri Q �'' <br /> ISTREET ADDRESS SITE PHONE II WITH AREA tone <br /> T s l S l t►fir fir/t�? o Lt I it - r�3S <br /> Y CITYC� l STATE IIP CODE t of Tanks /_ <br /> - 97OCkiTVA) � �L q- at Site lfl - <br /> A APPLICANTIBILLING NAME APPLICANT CONTACT NAME <br /> P t . N , (_C)�j. Cdrvr Pair y UVjft2L y.JDL�� <br /> I MAIL ADDF.ESS APPLICANT PH NE 1 MIT. AREA Cove <br /> a I ASO CU�i-�S fl Lati2Gi4 Sa5 cp}�3 2.000 <br /> N CITY ^ 1�� STAT TIP'COD£ TYPE of APPLICATION <br /> T VeAj1V/z� -� -- e Q'IiooI CLOSURE, INSTALLATION, ETC. ei ;-�(`C�f <br /> FACILITY FEE-= S100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1981 — 1988 —1989 <br /> T -- -- — <br /> i 1 <br /> E TANK FEE = $50,50 each TANK <br /> _ _ - - -_---- -- ------ -- --- - ....._.... <br /> F I Tanks _ _ x 154,00 1956 I --- I98T 1988 19813 <br /> A (multiply r by fee for <br /> C each year applicable) s <br /> I ._— <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25283 for applicability) <br /> T I Tanks x 156.00 1516 1981 1988 1489 <br /> Y (enter a,aauot and rear) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) - ---- -- — <br /> ._- _ ------7- -..- - -- <br /> O CLOSURE FEE = S90,00 each TANK, �I Tanks3 x 590.00 S �40,0o <br /> S <br /> , --- -- <br /> �R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E_ -__ --- --- ---- - - <br /> TEMPORAP,Y CLOSUf'£ FEE = $80.00 each TANK �I Tank; x 590.04 <br /> P PLAN CHECK ([nstallakion or Repair) _ - <br /> I L <br /> sA <br /> ?IPLAN CHECK; FEE 540.00 each SUBMISSION/RESUBMISSIGN S <br /> REPAIR <br /> 4iANK REPAIR F££ = 5914,40 each TANI; �_-._-_ .._.._.._... ITank x 5114.00_._____..-._.-FEE — --___ � --- <br /> �AIPIPING REPAIR/CLOSIVE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 4 I FF-_. __-__.._-- - - r _ _ <br /> JR <br /> UNAUTHORIZED RELEASE EVALUATION iCONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> applicable) (when applicable) (when applicable) <br /> I <br /> FEE = 120.0OIhr FEE = 535,44lhr FEE = 135.00/hr S <br /> TOTAL DUE a 7-0, 00� <br /> OFFICE USE ONLY <br /> 1117777.11F, F *u_ 111M. <br /> SkEEPS I COr.^ t Pl31," CODE IDIST CODE AMOUNT DUET AMOUNT RCVD CHtr i/CASH I RCVD BY DATE RECEIVED PERM IT I <br /> -0, <br /> 14 <br /> _-_ _i1IR�n AIIp� !mt g1BpmrtnrIrlm <br />