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IA <br />P <br />F <br />L <br />A <br />N <br />I <br />SAN JO, JIN LOCAL HEALTH DISTR :T, <br />UNDPRnknimn STnoicr Tauv Cone... r11 I <br />FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR — <br />A ------------ _ _ TOTAL <br />C 1986 1987 1988E <br />9— <br />r ITV�� - 1 <br />E TANK FEE _ $50.00 each TANK <br />F 1 Tanks _ s fee fo 1986 1301 (908 1989 — <br />A (Lultip[y (-hy fee for <br />C each year applicable) <br />L STATE SURCHARGE = $56.00 each TANK (see_CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br />T1 Tanks a $56.00 1986 1907 (988 1983 <br />Y (enter iiount and year) <br />C PERMANENT CLOSURE (Removal or Closure -in-place) <br />L--- --- - ---- -- ------ - _ <br />0 CLOSURE FEE _ $30.00 each TANK 1 Tanks r 190.00 <br />5.._ --- — 1 %O. rSU <br />U --- — — <br />R TEMPORARY CLOSURE (Only allowed one tiae'for up to two years) <br />E <br />TEMPORARY CLOSURE FEE = $80.00 each TANK, <br />------.----- I Tanks--- -- a 1 Y/yt 1 <br />P PLAN CHECK (Installation or Repair) -- <br />A---- - - ---- J _, <br />II PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION <br />REPAIR — -- <br />_—.--_- <br />R TANK REPAIR FEE = 1110.00 each TANK 1 in <br />E - - -- - = — <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, sinlmum one hour to be paid on plan subsittal) <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br />(when applicable) (when applicable) <br />(when applicable) <br />FEE = 130.00/hrL _ FEE = $35_00/hr FEE $35,00/hr 1 <br />TOTAL DUE 1 <br />OFFICE USE ONLY <br />SREEPS 1_1 CON? 1 I LOC CODE 01ST CODEJ AMOUNT DUE AMOUNT RCVD CHECK 1/LASH I RCVD BY DATE RECEIVED PERMIT 1 <br />_.....__....,._ <br />.....,..]ILLI_ IfiF1�PF v5 <br />FACILITY/SITE NAME <br />FACILITY CONTACT NAME <br />(3 (Cl a o I � <br />--T—R (� <br />� <br />STREET ADDRESS <br />�SbZ� <br />WITH AO94 LOOL <br />SITE PHONE 1 <br />CITY <br />STATE <br />11? CODE 1 of Tanks <br />ACU <br />at Site <br />APPLICANT/BILLING NAME_— <br />APPLICANT CONTACT NAME <br />MAILING ADDRESS <br />APPLICANT PHONE 1 "IT" AREA LOOK <br />CITY --- <br />STATE <br />11P CODE <br />IYPE of APPLICATION <br />- <br />LLOAUAL, IMLTALLATIO", RTC. <br />FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR — <br />A ------------ _ _ TOTAL <br />C 1986 1987 1988E <br />9— <br />r ITV�� - 1 <br />E TANK FEE _ $50.00 each TANK <br />F 1 Tanks _ s fee fo 1986 1301 (908 1989 — <br />A (Lultip[y (-hy fee for <br />C each year applicable) <br />L STATE SURCHARGE = $56.00 each TANK (see_CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br />T1 Tanks a $56.00 1986 1907 (988 1983 <br />Y (enter iiount and year) <br />C PERMANENT CLOSURE (Removal or Closure -in-place) <br />L--- --- - ---- -- ------ - _ <br />0 CLOSURE FEE _ $30.00 each TANK 1 Tanks r 190.00 <br />5.._ --- — 1 %O. rSU <br />U --- — — <br />R TEMPORARY CLOSURE (Only allowed one tiae'for up to two years) <br />E <br />TEMPORARY CLOSURE FEE = $80.00 each TANK, <br />------.----- I Tanks--- -- a 1 Y/yt 1 <br />P PLAN CHECK (Installation or Repair) -- <br />A---- - - ---- J _, <br />II PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION <br />REPAIR — -- <br />_—.--_- <br />R TANK REPAIR FEE = 1110.00 each TANK 1 in <br />E - - -- - = — <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, sinlmum one hour to be paid on plan subsittal) <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br />(when applicable) (when applicable) <br />(when applicable) <br />FEE = 130.00/hrL _ FEE = $35_00/hr FEE $35,00/hr 1 <br />TOTAL DUE 1 <br />OFFICE USE ONLY <br />SREEPS 1_1 CON? 1 I LOC CODE 01ST CODEJ AMOUNT DUE AMOUNT RCVD CHECK 1/LASH I RCVD BY DATE RECEIVED PERMIT 1 <br />