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' SAN IRAQU I N LOCAL HEALTH D AR I C:T <br /> UNDERGROUND STORAGE TANK PROGRAM FEE RORKSHEET <br /> _........._..._ .___. __.__.. ....... _. __...__...___.._ . . ....__ . _._...._ __._ .___._ ......................... <br /> _ <br /> c CArILiTY/SITE NAME FACILITY CONTACT NAME <br /> fto <br /> ,�r�co ������C°ll� OG�GT.._CG..-- -- _ __ _ .. ._._,__ 1�.��/l S_ �.P <br /> AD , S SITE PHONE 1 <br /> MIT" ARRA CODE <br /> T _ o �lya ......_...._._._. .. .._.. .... fel-_�. .......... <br /> Y CITY � ST TE ZIP CODE I1$ of Tanis/ g y <br /> at Site <br /> AAPPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P oa�rc S . ccl �e �s <br /> F' <br /> L _. NOR... ......�,�� ......._.._._. .. ._ .... ...... <br /> I MAIL ADDP,ESS APPLICANT PRE 1 M " <br /> ITN AREA COD <br /> __. <br /> A J-- <br /> ... <br /> N CITY p TE LIP CODE TYPE of <br /> T S/ / iL/ �(J I'1T�> C�(� /� CIOR VwE. tN9 MllAT TON ETr. <br /> ............................ .. __ ... ........ .. .._.. ..... .---._ -__._.. ... <br /> FACILITY FEE 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 13 1.86 1997 1988 1989 <br /> T <br /> ... <br /> E TAN, FEE = 150.00 each TANK <br /> ._....................... ............ ...................... ........ _.............. _......._ . ._..._..... .._. <br /> F A Tanks r (50.00 1986 1981 1989 1999- l� �1C7 <br /> A (multiply- by fee for ......_.............. ......_._....._._........._........ ._..._......._.._....._. <br /> C each year applicable) <br /> I __.._...._....._..__.._.._......._______.__...._.__............... ..................._.._._----._.._._.__._.___.._..... ..__._.. ...._._.__ _ _. ....._ _..__..... _. . .._.._.._.. .. . .. . <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25297 for appli(ability) <br /> I .............._...__.__..............._...._..... <br /> _..._..._...___.__..._,_. ....__._._...___._...._ ...__.__..__....__..........___. ._.__...._.........._.__._....._ ....._._...._......__.__--.------_......._._ _ __ <br /> T 1 TanV,s__/_ x $56.00 1986 1381 1998 1389 <br /> Y (enter amount and year) _..___......_..___...__. _._. _ <br /> t <br /> _.. ........ <br /> L ._.__ . _........._...._...._.._.._. _ ._._..._ ..................._ <br /> 0 CLOSURE FEE _ $90.00 each TANK I 1 ianNs x 130 010 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place....._.......... f <br /> S ..___._.___._._.._............._......_..__...._.______..___..__._..........__...__.. ._.._...__.._._......_....._.._......... .._. _ ...__. _.. _.-.. __.__. ...__.. <br /> U ......_........_..............................I..............................._ _..._____....._..__... _ ._._......_....._....._....._..._.. _..._.__.._........._.... ......__.__ <br /> P TEMPORARY CLOSURE (Only allowed one time r up to two years) <br /> TEMP 0PARY CL0SUPE FEE = 180.00 each TANK 1 Tanl� x 190 00 f <br /> P PLAN CHECK (installation or Repair) <br /> L_ ....__.____..__.__. ................_..__.._.._.._.._....__.._.....__............__.._....._.._..._ _..._...._.__.___..----. ..._.__.._. _._. __ _. _ ......... _.. ..._.. -___. ______ _.. _ <br /> A � <br /> )I PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION <br /> __.._....._._._.__.._..__.._................................ .......__..._....__._...__...__.._......____..._._.__._....._.___._-_..._...._.. ... ._ .._. <br /> _ . <br /> PEPAIR <br /> ---I. ........................._.. ......_.....__.........._...._...._...._...... ...................... ......................._.............. <br /> P TANK REPAIR FEE $110.00 each TANK 1 Tanks x filo 00 1 <br /> E _... .........._..__._............. ......................_......_......... <br /> __.......__..._...._.._....._._. ....... -_ _ <br /> f __ .............. <br /> .... _ _......._..... ....___._..._......... ._.. ...__.. ._ ....._ _ ......._. .__....._. _. <br /> A PIPING P,EPAIP./CLOSURE/REMOVAL (Fees are per hour, minimum one hour to bp paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SWL ING INSPECTION <br /> (when applicable) When applicable) (when applicable) <br /> FEE f°U 00/hr FEE 135 00/hr FEF <br /> TOTAL DUE : <br /> OFFICE USE ONLY f / d C7 <br /> f` <br /> IT"f FCN ,� ! I '� <br /> . C!i��i 1!glftllll���!�i��9�inh�1���1�!�lh,��I�G�I!!�N!R�II�inII,N�'i��l t���llipl�l�i 11lI�IJHi,a;nTili!ill� � 7B�7rU,;frhd��IflM►! , i, II 61n1I6q;,l din nq�! <br /> f S��EF.PS 1 COMP 1 LOC CODF DIST CODE AHUNT DUE AMOUNT RCVD Our WASH R.10 DY PATF PE .FI7FD P I r <br /> C211 3 l71 17,1— <br /> r <br /> 7/ <br /> �i�i ! ���GIiHAiln ..,7���� ��� 7M!1111(@�ii!�fIN!T1i4(�� <br /> .1 � r <br /> IT,l <br />