Laserfiche WebLink
SAN •AQUIN LOCAL HEALTH DIVICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> t yluoy--= o L e (--0 S <br /> SITE PHONE WITH ARIA coos <br /> L STREET ADDRESS T <br /> T STAT .IIP CODE 1 of Tanks <br /> Y C I Ty. <br /> at Site <br /> A APPLICANT/BILLING NAME — APPLICANT CONTACT NAME <br /> L CI Ilk <br /> �IN6 ADAPPLICANT PHONE 1 WIT" ARIA COOS <br /> _ � 1 <br /> qs� -- <br /> STAT lip C0 TYPE of APPLICATION <br /> T CIIY� cLawme, IMmiallaTlOM. en. <br /> �7} <br /> _..---- -..------ ------- --.. ----. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> T 1986 1981 1988 1989 <br /> E TANK FEE 150.00 each TANK i ((j -�� - }y,.l > /i �i� ✓' "� :��_- �f � ' <br /> A I TankultisT 1 lee for --1 -- 8 — <br /> F 1 Tanks / x 150.00 1986 1981 1988 1989 <br /> -- I _ <br /> C each year applicable) <br /> I --- - <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25281 for applicability) -- - <br /> T 1 Tanksx $56.00 1986 1981 1988 1983 <br /> Y (eniwl .Ruiit and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE _ $30.00 each TANK 1 Tanks__ z $30.00 <br /> S ---- — --- - — -- <br /> U --- -- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) _ <br /> E ----- - --------- <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks_ x 180.00 $ <br /> ---- <br /> ------- <br /> ...--- <br /> P <br /> -P PLAN CHECK (Installation or Repair) - <br /> A s <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION _—_--. <br /> REPAIR - <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks__ 0.00 <br /> z $11 s <br /> - -_ _ --- ..-..... <br /> ..._...—. — -- - ------- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plansubmittal) <br /> ----- -- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30 OO/hr FEE _ $35.00/hr FEE $35.00/hr $ <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> SNEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH HCVD BY DATE RECEIVED PERMIT 1 <br /> I1 <br />