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SAN JF ' QUIN LOCAL HEALTH DIST"CT .. <br /> UNDMROUND STORAGE TANK PROGRAM - FEE WORKSHEET - <br /> F FACILITYISITE NAME _ FACILITY CONTACT NAME <br /> A <br /> S cro�1 w�E�izm�o , cR J'T�, slr <br /> L STREET ADDRESS SITE PHONE t "I' "'A coo[ <br /> rmot - ���A -SS6 � <br /> Y CITY BTAjE IIP COD 1 of Tanks <br /> fie, - at Site — <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> . F ores <br /> 1 MAIL fi ADDRESS APPLICANT PHONE t WITH A[[A coo[ <br /> p . �Ox SGS' ��`'-_4 S,4 -8333 <br /> NCIT� STAT IIP CODE TYPE of APPLICATION <br /> � s� r ICLO[ [. INSTALLATION. [TC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR - TOTAL <br /> A -..._—_ - .-_--------- - — ------- <br /> T 98 — 1987 1988 989— <br /> I 1 <br /> V - <br /> E TANK FEE = 150.00 each TANK _ <br /> F t Tanksx $50.00 1986 1987 1988 1989 <br /> A (multipfy_1_by fee for <br /> C each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25281 for applicability) y <br /> I ---- - <br /> T I Tanks x $56.00 1986 1987 1988 1 1989 2i <br /> Y (enter iiiNit and year) q O <br /> I eN - <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L -- ------- - --- --- �— ..._..-- -- <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanks x 190.00 % SF 1 <br /> S -- -- <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 1 Tanks x $80.00 1 <br /> P PLAN CHECK (Installation or Repair) — — <br /> L — — ------- -- — — — <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION I <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK 1 Tanks x 1110.00 1 <br /> E <br /> P ---- -- -- --- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = f30.00/hrj ---- FEE = 135_001hr <br /> EFEE <br /> TOTAL DUE 1 <br /> OFFICE USE ONLY <br /> SVEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT t <br />