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9AN J IOU I N LOCAL HEALTH DIST CT <br /> UN . OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITYISITE NAME FACILITY CONTACT HAKE <br /> A 6-Z .,�2erVr - L1� 1 - MAS l R �' GALL lh�� <br /> I <br /> L STREET ADDRESS SITNIO <br /> HON I With Area Cade) <br /> T 1162-s . WiL ply W�`( 1) 4�q`5 <br /> Y CITY <br /> '9-1t96 r STATE ZIP CODE t of TANK'S <br /> l� <br /> 16A, `T520� at site �j �tE♦ � � <br /> A APPLICANTIBILLING NAME APPLICANT CONTACT NAME <br /> P W0019 6al,,TU&60 } � G jol-�ts jooes, <br /> I MAILING ADDRESS APPLICANT PHONE I (with Area Code) <br /> C P.O. 0149K <br /> N CITY STATE IIP CODE TYPE of APPLICATION <br /> T 'FU[_AfZ.r- CA, q,')L71� (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1906 1981 HS8 1489 <br /> T <br /> I 5 <br /> u - <br /> € TANK FEE _ $50.00 each TANK <br /> F I Tanksx $50.00 1986 1931 1989 1'f3'3 <br /> A (<ultipIy_l- <br /> by fee for _ <br /> C each year applicable) $ <br /> L STATE SURCHARGE = $56.00 each TANY. (see CA HEALTH t SAFETY CODE Sec 25281 for applicability) <br /> 1 <br /> T I Tanks x $56.00 1986 1987 1988 <br /> Y (enter a�io�int and year) <br /> $ <br /> C PERMANENT CLOSURE (Re<ova r Closure-in-place) .M O VA' - — <br /> L <br /> O CLOSURE FEE _ $10.00 each TANKI Tanks__ x $90.00 <br /> S <br /> U <br /> TEMPORARY CLOSURE (Only allowed one ti<e for up to two yea(s) <br /> E <br /> TEMPORARY CLOSURE FEE = 580.00 each TANK I Tanks---- $80,00 <br /> P PLAN CHECK (Installation or Repair) <br /> L i <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISs1ONIRESUBMISSION <br /> REPAIR <br /> k <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P I Tanks --- x $110.00 ; <br /> _ <br /> A <br /> I PIPING REPAIR/CLOSUREIREMOVAL (Fees are per hour, aini<ua one hour to be paid an plan subaittal) <br /> R — <br /> UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = $30.00/hr FEE = $35.001hr FEE _ $35.001hr $ <br /> TOTAL DUE $ 17(x. <br /> -OFFICE-USE OILY <br /> 7SUEEPSCOMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK IICASH RCVD BY DATE RECEIVED PERMIT I <br /> z.'M4'1 M'N�..MSI. .l. •4h. x .! r'4R.I f Y4' rtfti :1+!'1• '-t �-�`r :-....... .' <br /> tit ij Q31 1111bu <br /> `^."'�Ca¢�7•�� y��,Ky, �Pw.v{.,-�-'�T�w•^g-t T'�'�-'+}.fn�tx"�rcr+- 3��...,aF�c s7c'�"s'r�+a�.tt���f.r ..r� z�r�"$* "'�`�°''_"�-�r" <br /> .n <br /> fir" ',' � ;'°l.h�. � 7?IJ ySS .. Y r` •i',. <br />