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SANOAQUIN LOCAL HEALTH DWRICT <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />F A C. I NAME <br />C ARCD PA(AW-N -4 0 94t <br />FACILITY CONTACT NAME <br />fftNAMMEP A.. TA E D <br />I <br />L STREET ADDRESS SITE PHONE I WITH AREA CODE <br />I 1612 HAMV"EX GWIF (20q) 4-7b - 272-6 <br />T____J__ <br />Y CITY <br />5TD C*_ To Q <br />_]iTii I of Tanks <br />JE ZIP CODE FOUR. (4) <br />9-20-7 at site ,--- <br />A APPLICANT/BILLING NAME <br />--1 <br />APPLICANT CONTACT NAME <br />P <br />P 5PtjZ6 H°AU SEN e FE 9-S <br />MA;z1WC'H <br />L <br />I MAILING ADDRESS <br />11 <br />4W2, P45eV1GLS ROAD <br />APPLICANT PHONE I WITH AREA CODE <br />Sulfc 105 MW 349-305-7 <br />A <br />N CITY// <br />T N o r -T -H H (G H LAfJ P5, <br />LICATION <br />I STATE I ZIPTYPE of APPLICATION <br />A (0 CLOSURE, INSTALLATION, ETC. REMoVAL. <br />_5 -. - <br />FACILITY FEE = $100,00 each SITE ADDRESS per YEAR TOTAL <br />A. ............ ...... ... . .. ................. <br />C 1986 1987 1988 1989 <br />T <br />E TANK FEE = $50.00 each TANK <br />------- __...__._......_......_..__..» 9 1 FLO <br />F I Tanks x $50.00 1986 1987 1988 1989 <br />A (multipTi-i-by fee for <br />C each year applicable) ZIP <br />L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for app! LWOMMENTAL HEALTH <br />T I Tanks x $56.00 1986 1988 1399 <br />Y (enter ii556t and year) <br />C <br />- - -------- - ----- <br />PERMANENT CLOSURE (Removal or Clo,sure-in-place) 1 *Z <br />L <br />0 <br />_)-:1 <br />CLOSURE FEE = $10.00 <br />H <br />each TANK I Tanks Ax "130.00 <br />S__ <br />U <br />R <br />E <br />TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />- <br />TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x -180.00 <br />P <br />L <br />PLAN CHECK (Installation or Repair) <br />A <br />H <br />PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISGION <br />REPAIR <br />R TANK REPAIR FEE = $110.00 each TANK I# Tanks x $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 />F EE 130.00i1 ---- *--*-'*FEE-= $3*5".00"/'h_r._"_"*"'_"" ---FEE ­--i-3r­00Th r <br />.J. <br />TOTAL DUE f 3q0. 00 <br />OFFICE USE OHLY <br />SWEEPS # COMP # LOC CODE DIST CODE j P.U! I AMOUNT RCVD I CHECK WASH I RCVD BY I DATE RECEIVED1 PERMIT I <br />0 <br />