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SAN J UIN LOCAL HEALTH DIST*CT <br /> 11NDl: ROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> }W FACILITYISITE NAME FACILITY CONTACT NAME <br /> A E-Z e--ger ��� -j Mai aL, = cL i r y <br /> I <br /> L STREET ADDRESS Slr PHON 1 {with Area Code) <br /> vi A,`1 <br /> Y CITY`CA►oG ,lrQlq E ° lituTANK'S <br /> GA15ZOs site <br /> A APPLICANT/BILLING <br /> NAME APPLICANT CONTACT NAME <br /> (�1 Q�1 Cof�I�7 GIG Chi j0po jota66, <br /> I MAILING ADDRESS APPLICANT PHONE I (with Area Code) <br /> A <br /> ,0. P,�oX �27Q 2�R� CvB�-fq�o <br /> N CITY STAT$ IIP CODE TYPE of APPLICATION <br /> T -rLRLAfr.- ICA. rD (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1586 I-A7 !'388 158'3 <br /> T <br /> I I ; <br /> V <br /> E TANK FEE = S50.00 each TANK <br /> F I Tanks x $50.00 1986 1987 !'188 1'33'3 <br /> A (oultiply-f-by fee for - <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK, (see CA HEALTH I, SAFETY CODE Sec 2520 for appli:ability) <br /> 1 <br /> T I Tanks x $56,00 1986 1987 1588 111313 <br /> Y (enter aaaunt and year) <br /> C PERMANENT CLOSURE (Rerova r Closure-in-place) f�,-MO VA L <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK I Tanks-`;-- x 130.00 <br /> S <br /> U <br /> n TEMPORARY CLOSURE (Only allowed one tine for up to two. years) <br /> f <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK I Tanks-/ x $30.00 f �, <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSIONIRESUBMISSION $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE = $110.00 each TANK I Tanks x $it0.00 > i <br /> P <br /> A <br /> I PIPING REPAIRICLOSUREIREMOVAL (Fees are per hour, sinirua, one hour to be paid on plan subaittal) <br /> R — <br /> UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING - <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = $30.00Ihr FEE = $35.001hr FEE = $25.001hr $ <br /> TOTAL DUE <br /> OFFICE U f ONLY --- ---- ----- - -- - - ---- - <br /> SWEEPS 1 COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK !!CASH KCVO BY DATE RECEIVED PERMIT 1 ►}1I <br /> :9 ir.. .0�, -ar R..wy i'w.. y�i kt. 4•Ln+ .u+, . .-w,..r� p•i^1,..wrgr:r�Y.• » �n c. .. _.... �! <br /> LN P IJ QJ1 1"M <br /> .......�.�.,:-,ararr�nTt"�'�„'vq"�'t.ti�yaF'i'�^' "_'4,�'•.'c+:T"'rrt7y+, •�"w .•+e+,^cS�='��+s. <br /> r++N ass?ra _r ( - <br /> i <br /> y. ��4 ayc-e, <br />