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SAW OAQUIN LOCAL HEALTH GdkTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FI FACILITY/SITE NAME FACILITY CONTACT NAME <br /> za <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> Y CITY STATE ZIP CODE 1 of Tanks Z/ <br /> ? A � at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> Py <br /> L �- C- <br /> 1 MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> N I;ITYTATE ZIP CODELICATION <br /> APP <br /> _ LDOURE lHLICATION ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1589 <br /> T <br /> I $ <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks _ s 550.00 1986 1987 1968 1989 <br /> A (multipTy_I by fee for <br /> Ceach year applicable) <br /> I -- — <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> 1 -- ---__— --- - <br /> T I Tanks x $56.00 1986 1987 198B 1989 <br /> Y (enter mount and year) --- — <br /> 4 <br /> is PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = $"30.00 each TANK I Tanks_-,�_ x $90.00 <br /> S -- <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 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> IH PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION $ <br /> I REPAIR --- <br /> R TANK REPAIR FEE = $110.00 each TANK I Tanks x $110.00 $ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, ■inious one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (vhen applicable) <br /> FEE _ $30hr-t. FEE = $35.40/hr _ _~ FEE = 535,00/hrr <br /> _I.._ ---- <br /> TOTAL DUE $ G,0, <br /> OFFICE USE ONLY <br /> B IN in, <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> ���,I,., �I��JI I, RIG�'I�ll� I" flll !ll;£ I� all ffq� ll( 1911 ,( ➢ ! OW= � , <br />