|
' SAN ,XQl�E~•U .N LOCAL HEALTH. 13I:S'TR1CT
<br /> UHDERCS;QUND STOME THY. PROGRAM FEE WORKSHEET
<br /> IFIFACiLITY/SITE NA{1t FACILITY t:QNTACTNAl1E
<br /> ' I C
<br /> L�STREEi ADDRESS _T 511E,FHONE t WITH AACA V0bU
<br /> 1• CITY STATE ' I 1P CGDE �I of Tads
<br /> A APPLICANTIBILLiNG NAME IAPPLICA11T CONTACT NAME
<br /> Q �oaETZT H �..__..._._. _...____...._..� ---
<br /> L _.._._�_ __ ......._._ ._...__._.._..
<br /> [ MA[LIN^v AGDA.ESS P,PPLICA?{T i' ONE t urrH ngsn cnvs
<br /> A t... STAiE Ilf' CODE TYPE of APFLTEB.
<br /> N CITY c�oevar., yx n err„
<br /> IfACILIIY ff.£ ii00,0i1' eath SITE ADDRESS Per !'EAR -_ _.. .. .._ _..._...•,TOTAL.-,.
<br /> IAL.....,..._._.._:_..........._..._.___._...—
<br /> 19861
<br /> 148/_._.. ..138e .�_ [389
<br /> TI v ^-
<br /> E TANK FEE 150,00 each Tank; -
<br /> ��_................._.___ ........ ..I_. ...._e..., ._I ._..._.-1387.....,..T-_....._.'9f?8 ... .,_ [°89 I��`)6 "�"-•---_,....,_.-......_
<br /> �F t Tanis x 950,0.0 _...�)_�'_. _...-- -. _.._.�_._.._.._._...
<br /> A (Aultipiy i�by fee for I- I 1 5-a
<br /> 1, each year aopli;able) _—
<br /> LlSIAATE SUPCHARGE-= 150P.00 each TANT:_ (see' CA HFALTN�A S>!FF,TY CODE Se( 15207-for apolicability) rT
<br /> TIIeTanks_�. x ;56,;.0 r^ 198b 1 19:,7 ..- J988 ._ lei .... _ _..1�6
<br /> YI(eater aaount and year)
<br /> .....1_-..__'__._..._...----•--_..._,�. _.....__...�_.........__.... ,^._.........,>.._ ..... _. ..�...-----...._ va Vis,__— _ I toy ...._
<br /> :JPERMAHVIT C.LQSURI (Reaoval or Cl':sure-in-plate) --'—
<br /> 1L ..........�...•^_...__---- .00 earn lAN;:_._-.._.__..__.._.. .....- - ...... .. _..._ -.r-_.bTanks- Y mm"', -1 /, �Do
<br /> 0 CLOSURE FEE - 3 � -----^----..--^�- ----
<br /> U -
<br /> F TEMPORARY .C'OSURE IC!nly al lOwed one 04t- fur Vp to tuo year)
<br /> I E TWORARY CLOSUPE FEE ---X80.00 Fach TANK
<br /> TankFs-T • ►-S°C 6'0.,_._T.+��1. _ !�
<br /> IP,PLAN CHECK (,Instali-at-ion or_?epair)
<br /> lriA►{ CHE+;K FEE - si0,rr cec,l SU8'IS51O`{/r`,E;i,+;{MI.'tf
<br /> TAN): REPAIR, FEF - ti1lC.00 earl TAXI: �VVIRpMMENTq�.INt nT1 x o„ItO.tIC1._.. _ ._.._... '1_.. .... - _..
<br /> --PERMITIE LTH”-__..
<br /> I �SJrR1! S
<br /> A�PIPIN� Y.EPAIRI LOWS/1;E{t0!,AL (fees are w l;;ur, ainMA orr4 Y.6Jl to 5e paid or, pl,n 5ubKittal)
<br /> 1IUVA1ITHURIIE0 RELEASE EVA;UAT(flJI jCOt�STRU+.Ti011 if15PiCTION �+�'tPLiHG INSPECII"11
<br /> I 'vlen applt abtel !vhen aNpiitabie) t;,ten :�pp)icab)ei
<br /> I{EE FEE---Q.elnl'/h_l..... -- � FtC 35,(10/11t
<br /> _._....._.____. _. . _ TOTAL DUE 1Y
<br /> ..�
<br /> OFFICE USE ONLY
<br /> uu ,.r1f5• rnrl •r, n M?1 r' r �R1'I �yI�III�11� (r��I}�+ *?rtT,I III11,ryryry'�p}1 f�ry�,� rlt7'Inrr•�pl�lr•QI "F�I'!1 y. I IT'iF rk14 N11
<br /> ' Wily' I�.�A'' II I" fill 11: Y r'r1'+ �Y'I .aR{�rllU'� I•�la�I�I�li6il�l:h�II.L: I•H �'k11�Yllt .'IS
<br /> > �'I ll
<br /> ��'d �'�`��a��"i���� snl�':t',����,.��� :..�1�;II :�'�7�3,11:i1p, f�. �,:I.r���I',.. , DATE P 1 aE _
<br /> a „ c r I n !'!OUPiI DUE AMOUNT R i10 CHCf,Y 7ICASH �,,Va DY I TE .:CE D PED,MIT t
<br /> ,N�EPS t rOKP t Loi CSCE DISI CO.t
<br /> _ .....L . . _...,.. ........,._..._.._...___. ........ .._.
<br /> tD 2 r ,LI ��ii
<br /> 1! �. r�,.r w a'•,k -rri. 11gc n 9� n -r^ 1• A I`' a ;cT• I �n:h A N i•!' 001.
<br /> � • n t 1 11 I;l 1 t' J I'I �•�. �7�p1�k !'!1,�1��t�•��.� �IC �..1,
<br /> r,! .1 rIC pl 1';';f'�5•;�I;a ':114.h:,Agl^f ^�..1•' p I' I I` ,. r n,' 91 f 1 I' M 1� I' I e.l 41IV�'. 1 � Zk. ,�
<br /> it .���iica�43�f�,1�!��ikLj:k1�,'�prNi!:M,il.�a!2•II�!1•'r'.'.�� E!:�t';l�lS�l:41. I 1 y I��;�Il�e'il 1'I.I'r.�7�!Inf'^',Il•�I.�I'n1•!{.�a�=r�lij4 I'��I�1 !I j�!II,a�i.l d.1,lll�al' 111U.!f 1!{'1. Y��' IJI!:q !i'!l;lhgq:. I J' a l uul �I
<br /> m ..kA,=��_A I4.1'.n: 11..,1. 11:.,.a,L-r l.Er..p1A:p h,I.. I.,iA4�li�l .r. Il�'l,r� A'! 14•
<br />
|