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SANOOADUIN LOCAL HEALTH DWRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME pl�F OA IE.3�J,c n <br /> y(,LA- qX33 S`i4- a"73 <br /> L STREET ADDRESS SITE PHONE 1 WITH ARRA COOK <br /> 1 1d e . V1—sN -S"q- 027 <br /> Y CIT STATE ZIP CODE I of Tanks <br /> at Site <br /> A APPLICAmr/oILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> ��cc�'.Zzx� a v�Cq_— w_v ��s. _ m kE _FL ores _ <br /> 1 M INS AD SS �\ APPLICANT PHONE 1 WITH ARRA eocR <br /> N CITY STAT IIP CODE TY APPLICATION <br /> �°-" <br /> T NRC, Inn AUATION, RTC. <br /> � C �' - <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR _ — TOTAL <br /> 1 I 1986� •--1987--- 1383--� 1 ---•-- <br /> E TANK FEE • 150.00 each TANK <br /> F1 Tanks x 150.00 1986 1387 1988 1989 <br /> A (multipT-y'1 by lee for ----- <br /> each year applicable) _— f <br /> L STATE SURCHARGE 2 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks a 156.00 1986 1387 1988 1383 <br /> Y (enter Uii6fit and year) - <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — - <br /> L ._..... <br /> --- --- - — <br /> 0 CLOSURE FEE R 190.00 each TANK t tanks a 130.00 1 <br /> U - ---- ---- --__ - <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E _- <br /> TEMPORARY CLOSURE FEE a 180.00 each TANK t Tanksa 190.00 1 <br /> P PLAN CHECK (Installation or Repair) --- ____-_-_—._________..-.__-__-_-..._..-_•_---_.__-_ <br /> L . — — - -- --------- <br /> A <br /> II PLAN CHECK FEE : 130.00 each SUBMISSION/RESUDMISSION 1 <br /> REPAIR <br /> R TANY. REPAIR TEE : 4110.00 each TANK 1 Tanks x 1110.00 1 <br /> E - ---- - -- - - -- .._... _ _......._ __...... <br /> - - <br /> A PIPING REPAIR/CLOSURE/RENOVAL (Tees are per hours minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ 130 OOJhrI —`_ -- FEE = 45.00/hr - � - FEE = 135 00/h;l _ f <br /> TOTAL DUE t <br /> OFFICE BSE ONLY <br /> . '�lN�Ig1�19gI1'O Pq;�gEl"a1'ITJ� gg6tlltR✓Nq�OWGWlqllp I��!F <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AAOUNT DUE AMOUNT RCVD CHECK I/CASH "C%ID BY DATE EECEIVED PERMIT I <br /> . .�t� . .I �RII9 fiI�W6G69fl"7�W, . WMIN91.in,RM 109419INIIMI, <br />