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SA OAQUIN LOCAL HEALTH STRICT <br /> NDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET_ <br /> F FACILITY/SITE NAME FACILIIY CONTACT NAME <br />'f I- <br /> L STREET ADDRESS <br /> I_ i SITE PHONE 1 M TN AREA coos <br /> Y CITY �� �. C ��1�?��,-�. (�•b CC /f(ae- — <br /> STATE 11 CODE II of Tanks <br /> ._ _ _ 9 ,�IV 0 at Site <br /> P APPLICANT/BILLIN6 NAME - <br /> P APPLICANT CONTACT NAME <br /> L <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE t <br /> WITH AREA CCDE <br /> N CITY <br /> T STAT ZIP'CODE TYPE of P <br /> ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per�r YEAR - <br /> C ._,...,_,..,__.._...._ _._._ ._._.._. ._..._. _.. _ _.. _. .._.._..,__..,._. TOTAL <br /> T 1986 _....1987 1988 1989 "-----_ _ <br /> I - _.__.._ --•___.__._._._ _. <br /> V ---------•__ __._._ ..._ <br /> E TANK FEE _ $50.00 each TANK --- <br /> F I Tanks x $50.00 1986 1981 _._._.._..._. _..._.._ ._.--_._.._.._.__.... _._ <br /> A (multiply-Vby fee for1988 1989 qO <br /> C each year applicable) " "- ---- <br /> L <br /> -------L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH YSAFETY CODE'Sec 25287 for applicability) <br /> T t Tanks x $56.00 _ 1986 1987 <br /> Y (enter iiNht and year) ., 1988 1989 <br /> .0 .PERMANENT CLOSURE (Removal�or Closure-in-place) <br /> .._ ___ _.... _ <br /> O CLOSURE FEE - $' _.......__ "_" _ ----------- <br /> S ---- each TANK N Tanks <br /> U ._..�.__ ___, -.�.._,...._-------- -- - x (90.00 f <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E__ <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK <br /> _...,._.w. '. �.,-._`__ _ ----•--- �1 Tanks:-_ x $80.00 f <br /> P PLAN CHECK (Installation or Repair) ---- <br /> L _._._. <br /> M PIAN CHECK FEE M= $30.00 each SUBMISSION/RESUEM[SSION <br /> REPAIR <br /> P, TANK REPAIR FEE = $110.00 each h TANK "-- <br /> E _...-.... _. _ .__._-._.. . _ _.._.. ......I Tanks_ x $110.00 $ _ <br /> A a, <br /> A, <br /> (Fees_.�_„ -�._...._..._.____._.____.__ <br /> are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION T ON INSPECTION ^ <br /> (when applicable) (when applicable) SAMPLING INSPECTION <br /> I _ _ _ _ _ (when applicable) <br /> FEE ._..$30.00/hr.l.._._. FEE z $35.00/hr - <br /> FEE- $3,,.00/hr w $ <br /> OFFICE USE ONLY ,� �, T, n ; n�J_ y Z <br /> TOTAL DUE $ <br /> � <br /> OPTIONSii SIMON �9!I II!�q „WIN i. <br /> l� �Lt- �C T �' "V, / L <br /> �!� , � !�I �l�l' Il���il�uf�l�IiG ;t�lligl�l�il!Ir�ll(II(I�I!�iPufl�ll�i�!I�I�III�n�Ulillilflil�l6�l 'll�ln, .a�f!�ll�gn!' <br /> SWEEPS..t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PE, <br /> ..,........ <br /> ............ <br /> MIT I <br /> ��I!�� ASI I� I.!h►' I . .=�.. .._........... � .. _.� ..._._...,......... .. <br /> �1���6dC q�V�IIIBp99Bl,�llu�6l�ll �lIIlllnilili�l�lllllld��plll��� 191 .��iJJllf� l��l�lll INSl <br />