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SAIPJOAQUIN LOCAL HEALTH *STRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 1 FACILITY/SITE NAME FACILITY CONTACT NAME <br /> H c <br /> C QGirr/5�� ScJi� 5 �//C5 <br /> 1 Car//Ski <br /> L STREET ADDRESS �y SITE PHONE 1 WITH AREA CODE <br /> Y CITYSTATE 11P CODE I of Tanks <br /> —95-wf at Site - -- - <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P n <br /> P <br /> I MAILING ADDRESS APPLICANT PHONE I WITH ASIA CODE <br /> A _..✓/'0,�oK— /ys v _ ')v_9 - Y& & -3 � 3/ _ <br /> N CITY _ — STATE TIP COBE TYPE of APPLICAT10N _ <br /> T Sc% {vr� C� SIS 7U/ CLOeueE, INSTALLATION, ETC. SGmp�i i <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR — _ — TOTAL <br /> A..------ --.-.__— __.. — - - --- ---- <br /> 1 — <br /> V <br /> E TANK FEE _ $50,00 each TANK <br /> F 1 Tanks x 150.00 1986 1987 1988 1989 <br /> A (multiply-I-by fee for --- __ - <br /> C each year applicable) $ <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25207 for applicability) <br /> T I Tanks 1156.00 1996 19G7 1988 - 1989 <br /> Y (enter liiRt and year) _— _----__ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) - — - <br /> L..---- — ----- ------- -- <br /> 0 CLOSURE FEE _ $90.00 each TANK I Tanks x 190.00 $ <br /> S --- ---- �__ - <br /> UP. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E - - - ----._--— —. --- -TEMPORARY CLOSURE CLOSURE FEE = $80.00 each TANK, I Tanks x 190.00 f <br /> P PLAN CHEL'K (Installation or Repair) --- - - —— — - <br /> tl PLAN CHECK FEE = 130.00 each SUBMISSIONAESUCMISSION 1 <br /> --.— ._..__-.--._—.----- <br /> REPAIR — - --- <br /> R, TANK, REPAIR FEE = 1110.00 each TANK 1 Tanks x $110.00 $ <br /> E - ----__------ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be a' n submittal) <br /> 1 ,.--------- --- — - -- - -.._.._— -- _- - --- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/br FEE = 135.00/hr FEE = 135.00/hr f 3 Oo <br /> TOTAL DUE <br /> OFFICE OS[ ONLY <br /> SWEEPS <br /> E 1 NOMEPIflGGCOMP I a4�1G�i0E OI ST GC�OOEI�G��UGIt�GID�IE rI�A�GUUdNT RC�VO GG��C��r��G�GHGQI4b�ICGVDaOY ��GGGI@GN!IG�VG�IGJOGN GI�1'1�IGflG�1110GI1 <br /> - - E RECEIVED —PEP,MIT t -� <br /> 9n epi /� 1`/ of 3 5 `= <br />