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SAAOAQUIN LOCAL HEALTH DIRTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> .. . .............. " <br /> *,-,-,-''-,"",,-,*,--*,I------------------------ <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> L STREET ADDRESS "71 SITE PHONE # WITH AREA CODE <br /> I <br /> T nn <br /> Y CITY STATE iIP COOf <br /> a <br /> ........ J1 t Site of Tanks <br /> A APPLICANTIBILLING NAME APPLICANT CONTACT NAME <br /> P <br /> 3 <br /> L �Wh- <br /> I MAILING ADDRESS APP LICANTfHONE I WITH AREA CODE <br /> A <br /> ii�f <br /> N CI TY E[ IIP'CODE APPLICATION <br /> T ]� ti.. a,�.__„ -- � <br /> CLOSURE INSTALLATION, ETC. <br /> j <br /> CA �� <br /> A .........FACILITY FEE = $100.00 each SITE ADDRESS per YEARTOTAL <br /> ............................I .......... <br /> 1986 1987 1988 1989 <br /> ............ <br /> E TANK FEE $50.00 each TANK <br /> .............I...................1-1-1--........................ ......................... ........... <br /> F # Tanks x 150.00 1986 1987 1980 1989 <br /> A tTI <br /> itip -by fee for <br /> each year applicable) <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> I - —.1—.......... <br /> T I Tanks x 356,00 1986 1987 1988 1989 <br /> Y (enter ii5uht and year) <br /> C PERMANENT CLOSURE((­R`e`m`c—vaDr Closure-in-place) <br /> L ....... ................ <br /> 0 CLOSURE FEE = $90-00 each TANK I Tanks <br /> U <br /> RJEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> I <br /> TEMPORARY CLOSURE FEE = $80,00 each TANK Tanks x $00.00 <br /> ..............................................I--..................... <br /> P PLAN CHECK (Installation or Repair) <br /> L ............. <br /> A <br /> IN PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> ........................_ ........_ ------ <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANKx $110.00 <br /> E........... ....................................................... j-I—.-Tanks I-..- ................. .............. ............... <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> ............. <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> .......... ....... <br /> FEE <br /> FEE -z 335 00/hj FEE <br /> ............ <br /> TOTAL DUE S 30 <br /> OFFICE USE ONLY <br /> SWEEPS 5 COMP A LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK JJ/CASH RCYD BY DATE RECEIVED PERMIT I <br /> ...... ............. .................. <br /> .................. <br /> � � il� 1 � Il� !!ilfl,I{� iil{I!I 1,���1,l!Il�lnl�l{�!,i(II!I II>nl!Illllli!119,E��I( �!�!illl,��i I!II{IIQ,I� ��iln Iil!IAIIG�{Ill I?Ifll<B�°f!IIltlnlli I�IIII I{RI��III ..��{I�!lI ,IINil�9il(9��D1h'I °a {�lll{a <br /> 1 <br />