Laserfiche WebLink
SAN SQUIN LOCAL HEALTH DIE*ICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> IF FACILITY/SITE NAMEFACILITY CONTACT NAME <br /> A _ CTy OF E5Cgz oti <br /> Aavlal /QoXerrom <br /> L STREET ADDRESS SITE PHONE 1 WITH AmcA CODE <br /> 1 6�/O 3 /2CO7 Street <br /> Y CITY rs`a/On STATE IIP CODE 1 of Tanks <br /> C4, 953,0 at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> MAILING ADDRESSC pOX APPLICANT PHONE 1 WITH AREA eooe <br /> A ----U---. FTA <br /> __ <br /> N CITY /ry STATE ZIP CODE TYPE of PPLICATION <br /> T ���N/I�" ---_- �/�, ��O Cloeun[. INaTAILATIaH, [TC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A _------ -- ---- — —- -- <br /> C 1986 1981 1988 158'3 <br /> V :::: <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks _—_ c $50.00 1986 1387 1988 1989 <br /> A (multiply 1 by fee for <br /> C each year applicable) —�— --I --- $ <br /> ! �� <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I -- ---- -- <br /> T 1 Tanks x 156.00 1986 1987 1988 1389 <br /> Y (enter iiuuit and year) — ----- <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — ---- — <br /> L --------- ----- <br /> 5 CLOSURE FEE = $'30.00 each TANK --- 1 Tanks o? x $90.00 f /9-0. 00 <br /> U — -- —P. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E --- -- <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK, 1 Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) -— —— - —_— —— <br /> L ------ — --- — -- ------ <br /> A --- - <br /> �M PLAN CHECK FEE z $30.00 each SUBMISSION/RESUBMISSION $ <br /> 1(when <br /> FeeCarr avep /f0 . 00 <br /> RPAIR FEE = $110.00 each TANK 1 Tanks x $110.00AREPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> RRIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SANPLING INSPECTIONpplicable) (when applicable) / (when applicable) <br /> FEE = $30.00/hri FEE _ $35.00/hr FEE _ $35.00/hr f <br /> - - - ---1- ---- <br /> TOTAL DUE $ Z20 , 0 <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> hp-1 ErCFL2l 0 3 a 8(a <br /> ��, '1 <br />