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SAN A►QUIN LOCAL HEALTH DIAICT <br /> UNDERGROUND STORAGE TANK PR06RAN - FEE WORKSHEET <br /> fA FACILITY/SITE NAME _ FACILITY CONTACT NAME J"� f t� �t <br /> C <br /> I t s� <br /> t _ <br /> STREET ADDRESS 1 SITE PHONE 1 "{T" ARCA coot <br /> 1 C� 07 - L4-7 8 - -1 149 <br /> Y CITY TATE IIP CODELiit-o------ <br /> f Tanks <br /> Site 14 <br /> P APPLI MILLING NAME - APPLICANT CONTACT NAME <br /> I MAILING ADDRESS _ APPIICA T PHONE 1 "{TN ARIA coot <br /> N CITY _ <br /> T & AT 'itP CODE~�TYPE of APPLICATION <br /> l `1QwYRt, {NtTAL6AT0oN, IPC. t j <br /> FACILITY FEE =~$100.00 each SITE ADDRESS per YEAR <br /> p TOTAL <br /> ._._ ._..._.,.___ _.._._........_ <br /> C 1986 1981 1988 1989 <br /> T <br /> E TANK FEE • 150.00 each TANK A 19 96 <br /> F 1 Tanks x 150.00 1986 1987 1988 19 BL! HCP1_i'-' VICES <br /> A (multiply-I-by fee for ° <br /> C <br /> each year applicable) " _ 1 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> T tf Tanks x 156.00 1986 1987 1988 1989�^ <br /> Y (enter iiiiit and year) <br /> C PERMANENT CLOSURE� (Removal or Closure-in-place) <br /> L <br /> ...... 1 <br /> 0 CLOSURE FEE • 190.00 each TANK1 Tanks . x 190.00 <br /> U . <br /> — _ <br /> 9 TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E TEMPORARY CLOSURE FEE E—$80.00 each TANK 1 Tanksp M_x $90.00^- <br /> P PLAN CHECK (Installation or Repair) .._....___..__...___..._•� ��_�___••�•�--���_._.... <br /> A <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUCMISSION 1 <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK 1 Tank5xN$110.00 1 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees -"• V •F.M_�R�r.____._ .. _. _ <br /> I � are hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IHSPECTION�^ <br /> (when applicable) <br /> (when applicable) (when applicable) <br /> FEE = 130.01. FEE = 135.00/hr ��.M `__ <br /> FEE - $3,.00/hr $ <br /> TOTAL DUE <br /> OfftCF OSE OMIy <br /> SWEEPS 1 COMP 1 LOC CODE DIT <br /> CODE AMOUNT DUE AMOUNT RCVD CHECK i/CASH Rr n DY DATE RECEIVED PERMIT t <br /> _.._. ..._.............._........ .._.._.__._........_ .... _.... .._.... .. ........._......_._..._.__.G.......... 5T,................ _ _ <br />