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SAN OAQU I N LOCAL HEALTH n SR I CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ......._._....__.-.._._.......__.__._... FACILI. TY CONTACT NAME <br /> C _ <br /> I _...__-__..,.»....._-_..._..._._._ --- -"" -'.�. - ------� SITE PHONE # WITH AREA CODE <br /> L STREET ADDRESS <br /> I1 _._. M -- <br /> Y CITY STATE IIP CODE # of Tanks <br /> °I 331. at Site <br /> A APPLICANT/81LLIN6 NAME , APPLICANT CONTACT NAME <br /> r _ _ <br /> l _ 1 4�� O I S 1 f�til r�t ► o j--t-1 (7 ) <br /> I MAILINS AMPESS APPLICANT PHONE # WITH AREA CODE <br /> 7E�2l��,a'.j e��tti1 �� Zl•-lc �U �20 _ <br /> N CITY �� STATE IP CDD WE of CLOSURE AINBTALLATIION. ETC. <br /> ..._.0 . .._.._.__._.....__._.................p_..r __....._......._._....,......... -_.TO <br /> YEAR TOTAL <br /> IA <br /> FACILITY fE...u-q.'81n... each SITE ADDRESS per Y» _ <br /> C 1986 1987 1988 1989 <br /> I s <br /> E TANK FEE = $50.00 each TANK <br /> F # Tanks _ x 550,00 1986 1981 1988 19'89 <br /> A (:ultipIy_V by fee for <br /> +' each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x $56.00 1956 1987 f9AB 1389 <br /> Y (enter mount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-plate) <br /> L ......... ........_.._. --.__._.- —_..,.._..._...._._- _._ Lan <br /> O CLOSURE FEE $90.00 each TANK # x $90,OrJ5 .-._.____-_._..___...__.__-_______ .___._.....__._____._ ___ __ - <br /> .._...__.._....-_._...... _.._ ___.. __ � _-- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> _._..._.�.,_.._ 4 <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks------ x830.00 <br /> . <br /> P..._..........._.._...,.. . <br /> PLAN CHECK (Installation or Repair) <br /> L _._._.__.__.__........._............ <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUCMISS1011 8 -- <br /> L .R.-..._EPA.-._IR .... <br /> ....................... <br /> __-_...... <br /> ........ <br /> R TANK REPAIR FEE = $110.00 each TANK # Tanks x $110.00 8 <br /> E _..._.__,....,......__..........._._.__._....__..,__.._._._._..._.........._..._-_......- -_.._..._........_._.__..._._._�_...__. ___.,._. <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 /> ._ ......._..__._.... - ---- ... _ _ _ _ __ <br /> _. <br /> - ...----__ _..................... <br /> FEE <br /> _ 53[1.00/hr FEE $35.00 <br /> /fir/hr FEE _ $35.00lhr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> _ !I'.�11� �,��1# 'ti!Ill 11 111,I 1i .l l !I 1�I iii all�fllllfl ltl , i�1�1i11l IIP'iil i l�i�!nlrl!Irl, 1 .1�91n ill nllGllll ,pll�� !41!I !!�tl!I!{ �11G�1� 11i�lgl�il!Ii�!IIIIII I!,!Gif!ilil�zllll!!E910111111iI!IMEN >JAI!iIM111011311111R <br /> SWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUEAMOUNT RCVn CHECK WASH RCVD BY DATE RECEIVED PERMIT # � <br /> i ........... ._ <br /> wE�����1!it�v',(���i ►�P!�i�"��{{'���!nyy��II���IfIInyII,���'��j�p!I�Ilit�!!11>iltl�ltii�lt�,ll!I��III�I!�II!I�Il�ll!illi!;1?!I��IIIIIIII��llllll�ll!!'Il„IIIII111!li!Ifl�ll�illl��li!!1I�II�ll�llQilll1!J�11�1'�ill��itl!t�ll�ll�l>��Itlli II!I[I�II�IIII�III��I!�il �i�I�IIIIIIIIIIIEI!�III�II!ll!lli��&11 ��Il�l�.�ll�iill�l�llilll{�II��I'�lllt+� <br />