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SA*OAQUIN <br /> LOCAL HEALTH D <br /> RIOT <br /> ' �FACILITY/ <br /> U DERGRDUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> +ti 5I TE NAME _.._,_._...._.._._...._..._ . <br /> C _.._--_----•__.___ FACILITY COWiwi. <br /> ...-__,..----.�..�_._.__._._ <br /> NAME <br /> L STREET ADDRESS <br /> I ___ r�►y yP,� <br /> T------ <br /> r CITY <br /> CI .__-(•��:_r�'a , 1 , SITE PHONE I WITH AAREACaoe <br /> -- <br /> zip CODE <br /> A APPLICANT/BILLING ' _- of Tanks <br /> NAME <br /> P - —__ — _._ .�f� S` Site <br /> P APPLICANT CONTACT NAME <br /> I MAILING ADDRESS <br /> A _--.-,-.f <br /> N CI TY _.f' �'-Cc' APPLICANT PHONE I M�T� M AREA caaE <br /> C . <br /> T <br /> _.__ ..._......... TYPE <br /> -- - <br /> APPLICATION Pte, <br /> INBTALLATItlN, <br /> FACILITY FEE $100,00 c <br /> r� <br /> e <br /> E ADDRESS -`� ---- <br /> A ........,._,_..._.__.. each SITE per YEAR <br /> T 1986 ..... <br /> .._......_.._....._........ <br /> 1988 t 9s <br /> '` <br /> E FEE -•----_ <br /> TANK — - �� --- --- _ <br /> _ - <br /> $50.00 <br /> each TANK '------.----._._._. - <br /> F I Tanks _......._..... --- —_ - <br /> A _._ r fee an _ ------- <br /> .....__..._.._-._ ....__._._...._...._.__._.,__�� <br /> Ply If�by fee far 1386 ! 1988 .... __ <br /> each _. <br /> year applicabte} ,__.._._._..._...... <br /> L STATE SURCHARGE -- .� -`---- ---- <br /> f56.00 eachJTANK (See CA HEALTH SAFE Ty CQ252$7 <br /> T I Tanks x $56,00 -DE sec_ fora PPticabtlity} <br /> Y (enter i@55ht and year) 198Ji 1987 <br /> ....___ _._.,.._..,_ ._ - .—__..._ 13$9 �'--'-----•--..__ <br /> C PEP.MANENT_CLOSUP,E (Removal or Closure- i <br /> O CLOSURE FE --- <br /> S ._..__._ E <br /> U _.� _-_ I Tanks_ <br /> R TEMPORARY CLOSURE (Only alloyed one tine~for up to two year - $ <br /> TCMPTEMPORARY CLOSURE FEE = $80.09 each TANK <br /> I Tanks r '$30.U0 <br /> __ - --- $ <br /> P PLAN; _�"'--.•--..._._.._...�_.—.___.__ <br /> N�cK (rnstallat _- <br /> L <br /> N PLAN CHECK FE _ <br /> .. T$30_o4 each I5510N/RESUDMtSSION �—w-`�"�'"' <br /> REPAIR <br /> F <br /> TANK R€PAIR FEE _ $1t0,O4 each TANK <br /> Tanks x $!14,04 _._._.. <br /> A PIPING P,EPAIR'CLOSUREIREMOVAL (Fees are per hour, minimum one hour to be paid on Ian submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (vhen applir.able} <br /> PLING 11J5PECTION <br /> _..............._. <br /> ._......_ _...__ -— ..._.__.,.. fuf�en applicable} <br /> 00/h - - — _..._,.....___.__.__....-__._...__......_._.__ ..._.__ <br /> FEE = $30. r (when applicable) <br /> -.-_,...._...___.._._. FEE _ $35,00/hr <br /> FEE $35.00/hr� <br /> OFFICE us[ p,11y TOTAL DUE <br /> ll�� llIm lop. In 4! I ..'@fin, �.I, f 11011 ' <br /> !Illjil,�I,.1, fli!i <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RI IIIi�1�NCK <br /> ,I I/CASH R01) BY DATE RECEIVED PERMIT I <br /> I!lill'.4IIti 172 <br /> 1,.1111 "1s1"�II�1rKe '1 �� y g .... i } _. o.. 1 } ..14._.._.__............. _ -- -- ---_ <br /> " atm IP` �lRll441 �IIn��l! _..9i�lf�} � �I , q s <br />