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SAN ,1 QUIN LOCAL HEALTH DIS* CT <br /> 14, UNDERGROUND STORAGE TANK PROGRAM - FEE VORKSHEET <br /> AF FACILITYISITE NAME FACILITY CONTACT NAME <br /> 1 SIT PHON 1 (with Area Cudei <br /> L STREET ADDRESS '201 +b <br /> 1 1952- s. VIA w all <br /> Y CITY STATE ZIP CODE I of TA14KIS <br /> /SDG � GIS, g15zr� at S'to <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L APPLICANT PHONE I With Area Code) <br /> I HAILING ADDRESS <br /> A <br /> 0. PX�X )220 2aR) (r�BP�-fQ�o <br /> =ZIP TYPE of hPPLICATION ��l.0T LITY'(LILA � 1� (Closure, lnstailatiun, etc.$ FvQd]Afje <br /> FACILITY FEE = 5100.00 each SITE ADORESS per YEAR TOTAL <br /> A 4 <br /> C 1506 1587 19138 15fl9 l <br /> T ' <br /> 1 - <br /> V <br /> E TANK FEE = S50.00 each TANK <br /> F I Tanks _ x 150.00 1985 1`187 1589 l53`i <br /> A (oultip[y-Z_by fee for - <br /> C each year applkcable) <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Set 25287 for applicability) <br /> I <br /> T I Tanks x 156.00 1905 1107 1'100 <br /> Y (enter araunt and year.) - <br /> C PERMANENT CLOSURE (Reaava r Closure-in-place) PT,MO VQ <br /> L <br /> 0 CLOSURE FEE = $10.00 each TANK I Tanks_ _ x 190.00 1 L 7© <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to tva yea(S) <br /> E <br /> TEMPORARY CLOSURE FEE = 130.00 each TANKI Tanks x S90.00 1 �, <br /> P PLAN CHECK (Installation or Repair) I <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSIONIRESUBKISSIC14 $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE = Stt0.00 each TANK $ Tanks __ Y $110.00 I <br /> P <br /> A <br /> I PIPING REP AIRICLOSURE/REMOVAL (Fees are per hour, ainiaua one hour to be paid on plan subrittal) <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = S30.00/hr FEE _ $35.00/hr FEE = $35.00111r $ <br /> TOTAL DUE <br /> _ OFFICE OSE OILY <br /> UMMO <br /> SUEEPS 1 COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK IICASH RCVD BY DATE RECEIVED PERMIT I <br /> • . M' A. F n—.. . �1 •y.r. -M1w.J. (i{1 f.bJ.Y.l.'-yf�' •� �f•4. •�!^ LLS. <br /> .� :ter.. .r., ,.. , .•,,.. Y•M� cul- ri 'S <br />