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SAN •AQUIN LOCAL HEALTH DIVRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> T FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C <br /> L STREET ADDRESS , � y�� SITE PHONE 1 WITH AREA CODE <br /> 1 � 1 �__—E—Wes r� <br /> Y CITY STATE T►P CODE I I of Tanks <br /> at Site <br /> AAPPLICANUDILL� ING NAME/ APPLICANT CONTACT NAME <br /> P o- /7' V` h`SSDG! <br /> L -- ---- <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> N CITY S IP ODE TYPE of AP <br /> T --- �� -� CLOSURE. NETALLATIO r ETC. <br /> FACILITY FEE 1100.00$100.00 each SITE ADDRESS per YEAR YY - — -TOTAL <br /> A _�... _C -- - - <br /> EIV -- <br /> T —� 1986 --198 -1988 1383 �! 90 ----�A <br /> 1 - <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks z $50.00 1986 1987 1988 1989 q �� <br /> A leach yea tape fee for1-._— <br /> C each year applicable) $-�- <br /> 1 - <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> Tanks <br /> Y (entlriiouetxand6year) - 1986 --1987 �-_198 1983��Q�--- --- <br /> -._--- ----_ —_ ......_......_...... — ------ -- —}L—— -- <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) - - <br /> L -1-------_ —-_— -- -- <br /> O CLOSURE FEE _ $90.00 each TANK J 1 Tanks x $90.00 f <br /> S <br /> U _---- --- ---- — -- - <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E- -- ---- ____—_------ — -- - <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK I Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L ----- <br /> A <br /> ---A <br /> fl PLAN CHECK IEE _ !30.00 each SUBMISSION SUDMISSI01 _ f��f <br /> REPAIR - --- <br /> P. TANK REPAIR FEE = 1110.00 each TANKt tanks x 1110.00 <br /> E S <br /> - --- --- _--_--__.. - ....__........-....._._._.. - -- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) - <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (vhen applicable) (When applicable) (vhen applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> P�•. ,: _... a.... mi . ;, . � a�. �i� ii. N�I!I�ufli� JIII�IRV!frlRkLi�R d!�m�Mnm�'m�� 1 <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PEP.MIi I <br /> • r 1)_�— � -- ,— �/ <br /> I, 3i'! � II�flI N �i�PITN9 I Ilil9(�pll Pf �l�li �191�@9fi 1 4 �I� ImII� InP�I. I9�III�����II I�I� .I� If6i1 9NP1 T y <br /> E �� <br />