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9 151 �,. •��- <br /> SA 0 OAQUINLOCAL HEALTH RICT D° <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET N JPI .460 <br /> � <br /> .. ._.w�F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> a. <br /> pp <br /> C <br /> iI STREET ADDRESS SITE PHONE # " T" AREA CODE <br /> Y CITYtME—TA-0 01k <br /> I STATE ZIP CODE I# of Tanks <br /> tv <br /> �"�C AP APPLICANT/BILLING NAME 1 APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS p. APPLICANT PHONE # WITH AREA CODE <br /> A_—._._...._.._.. <br /> T CITY SAT 1IP'CODEm TYPE of,AINSTALLATION,PLICTIETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR m TOTAL <br /> A _.____.._....__.... _.__.� _.._._... _ __......_ .. m_.__.. __._._..__..___. __.__ _... _ ,_....__.__ . _. <br /> C _ 1986 � 1987 _ � 1988 1989 <br /> T - ..-.. <br /> i f <br /> E TANK FEE = $50.00 each TANK <br /> F # Tanksx $50.00 1986 1987 1988 1989 <br /> A (multiply' _by fee for <br /> C each year applicable)for - - $ <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH & SAFETY CODE'Sec 25287 for applicability) <br /> T # Tanks x $56.00 1986 1987 1988 _ 1989 <br /> Y (enter ii655t and year) - ---- - - <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place)m � �•0.p �� � <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK # Tanks.-k x $90.00 f <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 f <br /> P PLAN CHECK (Installation or Repair) <br /> L...... <br /> A <br /> !N PLAN CHECK FEE = $30.00 each SUBMISSIONAESUBMISSION �� f <br /> REPAIR _ ._�.w____.�. .�..�............_._.._.._...,�.... ...�. � ..�..... _._........___...._. <br /> R TANK REPAIR FEE = $110.00 each TANK # Tanks z $110.00 $ <br /> E_ ._..._.�..-----._....._._____-___._..___ ._ __ . .._ _. �..� .__-__...__...._._......_...._.._.........___._....... <br /> P ............ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE_ _.$30..00/hr. Y.T_� FEE= $3500/hr�_._. _� �....�... FEE 4�$35�00/hT <br /> TOTAL DUE _,. $ <br /> OFFICE USE ONLY <br /> KAMM <br /> SWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT # <br /> . ..... )._:.. , .Q. .................. ._.__...__ ........ <br />