Laserfiche WebLink
SAN IPAQUIN LOCAL HEALTH DI*ICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F fA�ILITY/SITE NAME _..-----_._.-.-- FACILITY CONTACT NAME <br /> -^— ---- - <br /> A Cl�c� Cola >330 /( Cc <br /> L STREET ADDRESS SITE PHONE t WITH ARIA Cao! <br /> 1 // 00 N" (�/��rx Zv <br /> T------ —.—— <br /> Y CITYSAE Z P CODE t of Tanks <br /> 'i 0 at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L- <br /> I MAILING ADDRESS APPLICANT PHONE t WITH AREA Coo! <br /> C <br /> N CITY STATE Z1P CODE TYPE of APPLICATION <br /> .T ,_-- CLCEYR[r INETALLAT ICN.-ITCH•-----_. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A -- <br /> T <br /> 1 <br /> V ----- <br /> E TANK FEE _ $50.00 each TANK _ <br /> - _..-----........_....------- _ ._...._... <br /> F t Tanks'�z $50.00 --�_-1986 -1381 1988 —- 1989 $ <br /> A (multipfy 1 by fee for <br /> C each year applicable) _ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25281 for applicability) <br /> T 1 Tanks x $56.00 1986 1981 1988 1983 <br /> Y (enter ieount and year) -_� <br /> .._ �. ---- <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> ET <br /> -- <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks_ 1 _ z $90.00 R O <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 t Tanks x $80.00 f <br /> P PLAN CHECK (installation or Repair) <br /> L -- <br /> H PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUBMISSION--- --_-— - $ -— <br /> REPAIR <br /> P, TANK REPAIR FEE _ $110.00 each TANK 1 Tanks-- <br /> •- -„ x $110_00 _..__......___..._...-s._....__._._-._._ <br /> - <br /> P -..... -- . ._.. -- --------------—__���__ <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 /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE _ $35r00lhr $ <br /> TOTAL DUEf 9Q <br /> OFFICE USE ONLY bit TJVJ(. -Z:t'� /g 000 6i�C. <br /> 'IIIA!'II!!P.IP.fl'�!�I!flifl!III�IIflflllfll!flllfllfllmfllll�,lfllfl'fllfl9ll91��lfiflllfllllfll!fl�� 18�'riiCi1�lllfll!flCfifl6�u1flllflifll!�fl1fllfl!�fl.�IMllfli!�I!iIflIU,�I�iIIBp11!111!"aflfil!I;!�IVIIfil�l�flli1lfllfl ,Ilii!Iflllf!I!ITifl1il�f11�11111flflflV!!fllmill��IIII�N�.fllfl�l�li�lfl�lf�?aflffll�,lfil�flflj <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT Rr,VD CHECK 1/CASH Rryp DY DATE RECEIVED PEP.HIT t <br /> _...................... --._......,..._......._._....._...-.............................__... .........-..._.... .. __.._._..._ _- ._.._............._.........,.___.._ __.__....- -. <br /> 1 9� cocr+cfl ?�, a �90�- doo ( qo <br /> Ir'@����ryrypp�m!fq @@,mmm.,�lflpllflllllflll��� I!!I��,Bfll�l?, !!;1 NMNgIMMN!';I!Iflll,.l�lflli i Im�l l@illi PflV��fll u Illfl�flMG�ll flI .,IIfl IIV�II M�IIfll6flflflll�!flflllgP.91 .IflVIIWNf9!91��IIII llllll�fliflla� <br /> I, 'fl� l VF" E I1BD <br />