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» It u VHbE <br /> SA*'OAQUIN LOCAL HEALTH *TRICT <br /> _ UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET _ <br /> �FfAILITY!�TE IIANE� � _...^- FAC1llT CONTACT NE <br /> ' c �aci 'I'C 1'►1ojass�s Co. « rn!�c <br /> L STREET ADDRESS _ $ITE PHONE 1 WIN ARmA good <br /> Y CITY S AT .11P CODE 1 of Tanks <br /> _ OC _AH ; — at Site owe <br /> A APPUCANI/ellll G NAINf � APPLICANT CONTACT NAME <br /> T vt e vrc ac o . LVi��C�iroHis <br /> iMA I G AO S APPLICANT PHONE 1 wlTn ARCA coos <br /> N c)ir ___ �y}y�Tt lir CODE TYPE or APPLICATION <br /> T laC rQ��{�• -�-. / q, ��C Z� CLOIOke� (IHtALtAT 10%. qT•rt. PQ wO vil <br /> FACILITY FEE : 1100.00 each SITE ADDRESS per YEAR _ TOTAL <br /> i _- 1986 1987 1988 1989 <br /> E TANK FEE a $50.00 each TANK <br /> F 1 links x 150,00 1986 19811988L <br /> 1989 <br /> A (Au,tipry-f-by tee for <br /> C A1th year applicable) —4 —_ � $ <br /> 1 <br /> L STATE SURCHARGE ■ $56.00 each TAHK (see CA AEAL14 f SAFETY CODE'Sec 25201 for applicability) <br /> T i Tanks x $56.00 1986 _ 1987 (980 1909 <br /> Y (enter iiauA and year) <br /> L PERMANENT CLOSURE (Removal or Closure-in-pla(e) � <br /> 0 CLOSURE FEE a {90.00 each TANK ( finks_ ( x 590,00 $ Q�� <br /> U <br /> P, TEMPORARY CLOSURE Only allowed one tiae for up to two years) <br /> TEMPORARY CLOSURE FtE 180-00 each TANK 1 tanks x 180.00 { <br /> P PLAN CHECK (Installation or Repair) <br /> A <br /> tl PLAN CHUCK FEE . $20,00 each SUBMISSION/RESUCNISSION $ <br /> REPAIR <br /> P. TANK REPAIR FEE a 1110.00 each TANK Y _ 1 Tanks1 1110,00 1 <br /> A PIPING REPAIR/CLOSUREIRf.N04AL (fees are per hour, ainimua one hour to be paid on plan subaittal) <br /> R ONAUTHOP,ItEO RELEASE EVALUATION _ CONSIRUCTIDN INSPECTION IsAnhm 1115PEctioN <br /> (when applicable) _ (when applicable) (when applicable) <br /> FEE = $35.00/hrl — <br /> TOTAL DUE f 90 <br /> OFFICE USE 0xv <br /> ARM'09Md�PQI 7.CJ�1k.'Ni�".��5�. �.., �"T��'3�e6'kuGSf�� °!�Vt^�4�°i�kFl➢ �`�a�r�k4tii '" '''I��evw1��N��uuu°r�� �41�ib x;s ,; a����aLC19I <br /> a <br /> SWEEPS CUBE AMOUNT DUE AMOUNT RCVD C)IECK WASH RCVD BY DATE RECEIVED PERMIT <br /> SP?S 1 COMP 1 LOC CODE <br /> I�Cr �lslBr � ll9NaS1tufi�3�°� t+tl�aF64s�11'aIW �19!aa�B�MI � t'�J��� �Gfri�kT)�A�du <br /> y <br />