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SAN TOAQUIN LOCAL HEALTH D -TRICT <br /> Aoo(INDERGROUND STORAGE TANK PROGRAM - FEE WORK9fte <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> CSelbal1 CoNsracfYaN <br /> L STREET ADDRESSC SITE PHONE t (with Area Code) <br /> r <br /> Y CITY STATE ZIP CODEY of TANK'S r� <br /> (A 5 at Site <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P S ba Id r F of row Ker) ��r p{ 7` <br /> L <br /> I MAILING ADDRESS M APPLICANT PHONE t (with Area Code) <br /> C 0• fox 1 z� za?-9vS. -2l Sz <br /> N CITY STATE IIP CODE TYPE of APPLICATION Ta (� RCtnoVal <br /> CA s y p (Closure, Installation, etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 1986 1987 1988 1989 <br /> I $ <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks z $50.001986 1981 1'388 1939 <br /> A (multiply-i-by fee for <br /> f each year applicable) <br /> ( STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> T t Tanks z $56.00 1986 1987 1988 1989 <br /> Y (enter 3ao5nt and year) <br /> $ <br /> C PERMANENT CLOSUREI (Remova or Closure-in-place) (G{,ho,�( �Fydnt 3 S.eyo <br /> L <br /> 8 <br /> CLOSURE FEE _ $90.00 each TANK t Tanks- z 190.00 $ <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 Y Tanks z $80.00 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> R REPAIR <br /> EE TANK REPAIR FEE _ $110.00 each TANK t Tanks z $110.00 f <br /> A - <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATIDN CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE'u'=' <br /> $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> IN <br /> MF <br /> SWEEPS $ COMP t LOC CODE DIST CODE I AMOUNT DUE AMOUNT RCVD I CHECK I/CASH RCVD BY OA TE RECEIVED PERMIT I <br /> .yf.....gv+nV. �.. _ I %' `v li. • —.y41'/I iipf-Y"f .[ <br /> ..,.a..�.�.....�.���, u. l�(i 1.)✓..x Pauly i$:��:'.S.YQI_�e n.0.T.... <br /> t <br />