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SANWAQUIN LOCAL HEALTH DO RICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> [FAl-'F-A*C"1LITY/SITE NAME (FACILITY CONTACT NAME <br /> i <br /> C A ACO F A,C,I WT STA6MAcf-0 <br /> L STREET ADDRESS SITE PHONE # WITH AREA CODE <br /> I 'Zqoib PFM AMM ftLT PF-I\)F, (zoo) 475- 5557- <br /> T <br /> Y CITY STA 1�of Tanks" <br /> r lip CODE <br /> 5'FO C4--70�J �C6] q 7 at Site <br /> ............ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P 3AB V-GHAU5eFJ <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> il <br /> .1 4w R-05SVILLE P-OAD 5vit!- to?> (q 'o <br /> 30 - 30 57 <br /> A <br /> N CITY ISTATE ZIP'CODE TYPE oiAWICATION <br /> IQORJ7 j H(6H (-Ark)D-5 CLOSURE, INSTALLATION, ETC.REKOVAL <br /> ............ <br /> FACILITY FEE $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ...................................... .... <br /> C 1986 -**I*9'8"9­ C-*"*------ <br /> T 010 <br /> V <br /> E TANK FEE $50.00 each TANK <br /> ............... .......................... <br /> F I Tanks A x $50.00 1996 1987 1988 1989 <br /> A u l t i p Ty -by fee for <br /> Ceach year applicable) <br /> L STATE SURCHARGE= $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x $56.00 1986 7 1908 1989 <br /> Y (enter iiKnt and year) -------------- -_.__._.__ ............ <br /> .......... <br /> C EERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> S ------*,---------",--"—*--**-""----,*-----"--- <br /> 0 CLOSURE FEE = $10.00 each TANK I Tanks- x $90.00 1 <br /> R TEMPORARY CLOSURE (Only allowed one time for up to tvo years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK Tanks x $80.00 <br /> .-..--............................ ...................... <br /> ........................ <br /> P PLAN CHECK (Installation or Repair) <br /> L.......... ............. <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION <br /> REPAIR <br /> ........... <br /> P TANK REPAIR FEE = $110.00 each TANK Ii Tanks x $110.00 <br /> E ----------.................. ...............I......... ................................................. <br /> P --------------------------------------- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I .............. ------------------------- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> ........... .............-------- **--­-.---"­'­------------ ---------------- ................................ <br /> FEE = $30.00/hr FEE $3500/h FEE <br /> $355.0 0/11 <br /> ........... ----—--- <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> C" <br /> II <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK RCVD BY DATE RECEIVED PERMIT I <br /> ...................... ........................ ......'....................I........................... ................................ <br /> 'n -! I .................................. ...__..__.�.i.l-lli.!.I-GIGTT111,101 IN 1 71 <br /> 10 <br /> lip <br /> Till'r All <br /> . 'LIJ <br />