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bAMAQUAN LOCAL HEALTH DI RiCf <br /> GROUND STORAGE TANK PRO6RAN - FEE WORKSHE� <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A Ma r Ke�f 5-f-rcet Pa r Ly, 51r(1 cf u <br /> I <br /> STREET ADDRESS SITE PHONE # (with Area Code) <br /> L <br /> 1 13 LlSV 2 <br /> T ' <br /> Y CITYS +o C- �� C JE iI 5� Y of TANK'S I <br /> yi fj p at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P (' ( o SfiocKlan — ub is work-5 <br /> L <br /> 1 MAILING A RESS APPLICANT PHONE # (with Area Code) <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR I TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> A�rcaoi� d '`66 8788 — f B <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanks I x $50.00 1986 1987 1988 1989 <br /> A (multiply-I-by fee for mo 00 <br /> C each year applicable) ��� sO49 SD— o:l" $ 1-So • (Do <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applica ility) <br /> I <br /> T # Tanks I x $56.00 1986 1987 1988 1989 <br /> Y (enter Soount and year) `6 ( $ ,( DO <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK # Tanks-- -- x $90.00 $ 0 . 00 <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 # Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A $ 8— <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK # Tanks----- x $110.00 f <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> SWEEPS # COMP # LOC CODE DIST CODE I AMOUNT DUE I AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT # <br /> X339 CITy013 <br />