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SAN WAQUIN LOCAL HEALTH D ORICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FI FACILITY/SITE NAME _ — FACILITY CONTACT NAME <br /> I- <br /> L STREET ADDRESSr SITE PHONE t NITN AREA COOK <br /> I IL 27 s <br /> A6 HkAA1 I Mo3;cE 2dff ub ye/O - 2 S v <br /> T <br /> Y CITY STAT ZIP CODE t of Tanks <br /> .S)C/CTD� C/f at Site <br /> AAPPLICANT/BILLING NAME APPLICANT CONIf NAME <br /> F <br /> F <br /> L -- -- ----- — <br /> I MAILING ADDRESS _ APPLICANT PHONE 1 NIT" AREA CODE <br /> A. --- <br /> N CITYST T 1 OE TYPE of APPLICATION <br /> T L CLOSURE, INSTALLATION. ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ..... ---- --- — - - --- -- - -- — --- <br /> T $986 1987 1988 —1989 <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks [ _ x (50.00 1986 1987 1988 1969 -- <br /> A (multiply i by fee for - c <br /> i' each year applicable) '5 <br /> 7�D 5U aZ f GO c <br /> I — <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I - -- - <br /> T 1 Tanks__ E_ x $56.00 1986 1987 1988 1989 <br /> Y (enter amount and year) - G <br /> �� — f • <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L - - <br /> S CLOSURE FEE _ $90.00 each TANK t Tanks_ _ x $90.00 f 1 <br /> U -- — — <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E -- — -- <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK TI Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> IL - <br /> A <br /> IN PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR — <br /> P. TANK. REPAIR FEE = $110.00 each TANK t Tanksx $110.00 f <br /> E---- <br /> A <br /> --A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I -- -- <br /> IR UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION — SAMPLING ItISPECTION - — <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = (30.00/hr FEE _ $35.00/hr FEE = f35.00/hr f <br /> - .-. ..., _ — _---- TOTAL DUE <br /> OFFICE USE ONLY <br /> 4i!III��G�?9� ?91� ii'P MUNWIR?04�'II�� 14 Y�GlfRfll� Iw[ EMTl11 I� ��3 G ?8fd �VIMG�1C� <br /> EP —... � <br /> ,WEEPS 1 COMP f L0� CODE 01ST CODE AMOUNT DUE AMOUNT pf,VO 1/CASH RCVD BY DATE P.ECEIVED PERMIT f u <br /> rmmTEP411115 Sr 17 <br /> �ri ? � �m tulliN�l@9fd1V1, !ri9l,?�a1 !G�I!li"il?I�.1ICIlllfl�GII�!F mP�ll� ;T�pN1��..19�If?I?I�I�VI�GIIIF !91?If&h� C <br />