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A ff <br /> SAN&AQU I N LOCAL HEALTH D IDR I CT <br /> UNDERGROUND STORAGE TANK PR06RAN - FEE NORKSHEET LI <br /> i� FACILITY/SITE NAt1E �� "�-- <br /> �ELTr} Ck)MM 010J F�' <br /> ILITY CONTACT NAME <br /> r Sr4a AQUjj �C C�C� 7 D. 1 M. Cr 4A rel fic. <br /> L STREET ADDRESS <br /> r/ ff� SITE PHONE 1 M1TN AREA C04; <br /> T S� ! �4vt`.Ucl <br /> Y CITY aoSTATE IIP CODE I of Tanks <br /> p::�. at Site 62 <br /> A APPLICANT/BILLIN$ NAME <br /> F � , 14 �� � � APPLICANT CONTACT NAME <br /> L ll hao- C ELy"'-Jous <br /> I MAIL G ADDRESS <br /> ( <br /> (24b" 'q APPLICANT PH NE t WITH ARCA CODE <br /> TCITY STAT <br /> a1�JZA C 3040E TYPE of APPLICATION <br /> ' CLOSURE, [IIF TALLATiON, CTC. /)i sem.r�1 <br /> �AFACILITY FEE = 1100.00 each SITE ADO2ESS per YEAR (�(.(��VK. <br /> Cl - TOTAL <br /> I 1986 1581 1588 1484 <br /> V f <br /> E TANK FEE : 350.00 each TANK <br /> F I Tanks _ _ x 559.00 I955 1381 <br /> A (muftipry 1 by fee for 3588 1985 <br /> C each year applicable) <br /> L STATE SURCHARGE = $56,00 each TANK (see CA HEALTH t SAFETY CODE Set 25287 for applicability) <br /> ( <br /> I I Tanks x s5E,04 1585 1951 <br /> Y (enter mount and year) 1488 1589 <br /> C PERMANENT CLOSURE (Removal or Closure-in-plate) <br /> L -----�_ <br /> O CLOSURE FEE _ )'10,00 each TANK <br /> - 1 Tanks 3_ x f50,Oq f .00 <br /> �P. TEMPORARY CLOSURE (Only allowed one ti4e for up to two years) <br /> E <br /> ! TEMPORARY CLOSUF�E FEE = S80,00 each TANK <br /> - I Tanks x 190.00 f <br /> IP PLAN CHECK (Installation or Repair) <br /> IL -- <br /> iA <br /> Intl PLAN CHECK FEE = 130,00 each SUBMISS1011/RESUEMI:-S!G!1 <br /> I S <br /> I <br /> )REPAIR <br /> T�---- <br /> 1 F TAH): REPAIR FEE - 1110-00 <br /> !fi�-A ea.h TANK <br /> Tanks1110.00 <br /> - <br /> ---•-- x ! <br /> �A+PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> [R UNAUTHORIZED RELEASE EVALUATION jCGNSTRUCT(GN INSPECTION <br /> (when applicable) (when applicable) SAMPLING INSPECTION <br /> — r--------- ----_— — - ------ (when applicable) <br /> FEE = 330.00/hrL <br /> FEE = 135,00/hr 1 <br /> OFFICE 115E OILY <br /> TOTAL DUE <br /> -WEEPS I COP- f j 1 TIariQfa"�u"�Id�iFL��,�� #,' u�� �`��f411�411 <br /> kl LJ,- CGDE DIS, CODE At1GUt,' DtJ, � ASOUt(T RC'dOy''CHtr I/+ASH RCVO 01' DATE RECEIVED PERMIT ! <br /> n,. ea 44 _ <br />