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SAR OAQUIN LOCAL HEALTH d RICT�� <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME —-— - - - ---- FACILITY CONTACT NAME <br /> �C <br /> I•. Gtlil�lL!__TGE —_ — w_ Q9NJ�Gl2EL <br /> L STREET ADDRESS SITE PHONE # NITN AREA eooE <br /> z�5 I _ <br /> Y CITY STATETIP CODE # of Tanks <br /> S pnj at Site 3 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P .DAV O M(2cAceJ <br /> L - <br /> I MAILING ADDRESS APPLICANT PHONE I NITN AREA coag <br /> A aoCI -6 - 9� <br /> N CITY STATE ZIP'CODE TYPE of APPLICATION <br /> T CLCENRE, INITALLATIaN, ETC. <br /> JeA <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A..........._..- ._......... <br /> T t9B6 1987 1988 1589 �- <br /> V- - - _ <br /> E TANK FEE _ $50.00 each TANK <br /> t Tanks __ _ z $50,00applicable) 1986 �— 1987 - 988 - 1989----E- <br /> F -- <br /> A (muItipry <br /> Thy fee for - <br /> C each year applicable) $ <br /> 1 <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH b SAFETY CODE Sec 25287 for applicability) <br /> I - <br /> T I Tanksz 456.00 1986 1987 1988 1989 <br /> Y (enter adnt and year) -- --- <br /> _—.----------- - - -••-- � ---_.. <br /> C PERMANENT CLOSURE (Renoyal or Closure-in-place) <br /> L -- <br /> 0 CLOSURE FEE _ $90.00 each TANK t Tanks--/_ z $90.00 f d - <br /> U ....------ <br /> R <br /> -•P, TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E - <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK I T � <br /> f _— - <br /> ___._.-.-.....___-____ • -_ _p°�t$1 X00 f <br /> P PLAN CHECK (Installation or Repair) Ft <br /> �y <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> _-�_ ---._ —__ WE41 nA -� <br /> ........_....------ _—— — .—. —_----- — ►_ Nr" — <br /> REPAIR <br /> P. TANK REPAIR FEE _ $110,00 each TANK I Tanksz $110.00 f <br /> E------- <br /> P <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 INSPECTION7SAIPLING INSPECTION <br /> (when applicable) (when applicable) en applicable) <br /> FEE - 430.00/hr f -- -�— FEE = 435.00/hr�- _ $35�00/hr - -- f <br /> TOTAL DUE <br /> OFFICE USE ONLY — <br /> �II9lm@9999! 99991 1�111I!113'11119919!9 N1 1IN,Tl g1119191 Ig191 "ggfiB411gfl�qil�pfiq!lginfflg1lq'!!1�9gQ1!I�u�l!!191!il@KVI�I"V!II!II!!fl!ili�IfglGlgifg1fiqlllTl!Illl!Ilq!k1!;iuglilil fllgglG1qugCU!IIEil1�lfi�IIIIN! Vf�lgglillllVl!gF!!ill!ImJ711Aq' <br /> SNEEPS I COMP I LOc CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT I h <br /> ---- ..._....__.._....._... _...._.-....- --- <br /> f\ILNU 4 3 1�.X 3 4 to. --S a'- 60 V 5 CT- a <br /> ��q!11�71�q��tIN�94'�u��'�q�919+1��m��1.!ilfl!11911!19119�19�IIII!g1199911!111191911i611!1P11119!919199111!';I�ifg9q�!1�91i1'1i999191!91919!11111i!1 991i19Pd1111AG91911911�!999111911119999191VI9WII9LgIli1111�11�1111111119919119P9111p!91 i1111�199�1�111N1!I�@�1191u� <br />