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SAN '"JAQUIN LOCAL HEALTH DIS..a2ICT <br /> }� UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NA "" �� FACILITY CONTACT MAKE <br /> A TA <br /> C <br /> 1 <br /> L STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> I 3 / - 6S-7- 6 67 <br /> r <br /> Y CITY A/ STAT ZIP CODE t of TANK'S <br /> Site <br /> AAPPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P �� s S��6,eQ/C -5 <br /> P <br /> L <br /> C MAILING ADDRESS 7� / !^ /' L /3 �� APPLICANT PHONE 1 (with Area Code) <br /> (9 ! v ,/r7 r <br /> A <br /> N CITY STAT ZIP CODE ITYPE of APPLICATION <br /> I S 7 S Z p Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 [•388 1989 <br /> T <br /> I p c)c) OC ) <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks: x $50.00 1986 1987 1988 1939 <br /> A (multip y 1-by fee for <br /> L each year applicable) <br /> 1 <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> l <br /> I 1 Tanks_3_ x $56.00 1986 1987 l`iB8 1989 <br /> Y (enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) 2S <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK I Tanks3- x $90.00 $ <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed cone time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks x $80.00 f J <br /> P PLAN CHECK (Installation or Repair) <br /> LE <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION R E C 4 V E D <br /> REPAIR <br /> Wit— <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x $IIOANVIRONMEN <br /> P <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 EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> M. t� aK�'...a.. LSM+.Y5Y4rp..1v[xMf 'Y N'•h MMYY. 1'('.. a.. � 1 M „�.a9. --f x 'f . <br />