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SA " OAQUIN LOCAL HEALTH DIWRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> . .. ........ <br /> �1 , k FACILITY/SITE NAME FACILITY CONTACT NAME f <br /> C r' <br /> I -- <br /> L STREET DDRESS SITE RHONE # WITH AREA 0006 <br /> I <br /> T __. ._..__ _. _ -- <br /> Y CITY STATE IIP CODE of Tanks <br /> at $ite <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L t� <br /> 8 c. <br /> I MAILING ADDRESS �^ APPLICANT PHONE t WIT" A A CODE <br /> A _ <br /> T CITY _ TATE ZIP'CODE <br /> ® ClQBUR N 6ATIQ ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A_....._...._-._._.._.._.__.........-----------__---_. __._____._.._......._..........__...._....._-_...____._._.__._. _ ..._..__.___.__._..._..__ ..... <br /> T 1986 1987 1988 1989 <br /> E TANK FEE _ $50.00 each TANK <br /> .........._........_............. <br /> .._._.__.___ <br /> F # Tanksx $50.00 1986 1987 1988 1989 <br /> A (multipTy�#-by fee for <br /> C each year applicable) <br /> i $ ---- <br /> ._ . __.__..._.__ .__.... .__ . __ _�. _ _ <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 1987 1988 1989 <br /> Y (enter am6unt and year) _ -- - -----• —_. _ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L..._._._. __.__._..__.._..._.___...._ <br /> 0 CLOSURE FEE _ $90.00 each TANK �# Tanks x $90.00 $ <br /> S -- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK <br /> �.__.___._................. _..___ .. _ _. Tanksp� qA x $90.00 <br /> __..._..._._.__.._............___ <br /> P PLAN CHECK (Installation or Repair) <br /> L-------__ <br /> A <br /> I11 PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUDNISSION $ m <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK # Tanks x $110.00 $ <br /> E ------ <br /> P....................._.............._........................._..... <br /> _.._ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I................................ <br /> ...._... <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE 335.00'/hr FEE = $35.00/hr $ _ <br /> TOTAL DUE $ _ <br /> OFFICE USE ONLY <br /> Moi .. � ' n` 1.INI;�fi 1Nt11 16111"11. ► �I`aNil.'illid{N(kIINI� � i r I I.. '�aka'IAiill II4 IIIFIGIIAmINImIINIU! Gllllitili�l IAM IIA�� <br /> SWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHEC �C A' RCVD BY DATE RECEIVED PERMIT # <br /> 2.................._....... ... ........... ................ <br /> .........__ _ ._ ... t _._ _..._................. _..._.....__.(.(__....____ <br /> ry <br /> 11101011110M!6111 x ., aln <br />