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• SAN OOAQUIN LOCAL HEALTH ARICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME II I FACILITY CONTACT NAME <br /> CNF-VRDU MA2-TI EZ) EIiaDtp <br /> L STREET ADDRESS SITE PHONE I WITH ARSA COOS <br /> I — so8 t� G ta.�7El� k�a C209) 4(o7-- 119 I <br /> Y CITY STAT ZiP CODE t of Tanks <br /> 9526(o At Site 3— — <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> LRot3ee f {�• Lc>; �/tssoclaT RIc1c (`'��1�uL_cY <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> n IS3? oWg-- Ave ' 211 _ L2 (Aq-4CO3 <br /> 1 CITY G^cR.A jC-0 � - Si TE [P`CODE TYPE of APPLICATION I IDvoI <br /> 1 SSZ�j CLOSURE, INSTALLATION, SIC. <br /> $. li TAIIq 1A-6d <br /> r FACILITY FEE = 1100,00 each SITE ADDRESS per YEAR - 117 TOTAL <br /> 1 1986 1987 19881989 - <br /> v —_ L 1 b '1 <br /> E TANK FEE _ ach TANK �e_Do <br /> F 1 Tanks x 150.00 --- 1986 1987 1988 —1984 - <br /> A tench year app fee for —�� -- <br /> C each year applicable) 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH b SAFETY CODE Sec 25281 for applicability) <br /> 1 ----- ---- — - <br /> T 1 Tanks'__` x 156.00 - 1986-- - 1987 - -- 1988 - 1989 �- <br /> Y tenter aeount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L - ----- ------...-.�-- ----- - ---- I 1 �� - <br /> 0 CLOSURE FEE = 190.00 each TANK -�1 tanks_- _ x fae ee �5y ,. <br /> S ------ - <br /> U ------------ - -- - <br /> R TEMPORARY CLOSURE (Only ailoved one time for up to tvo years) <br /> E ---- --- ----- ----- — - <br /> - - ------ --- <br /> iEMPORAP°Y CLOSURE FEE _ $80,00 each TANK 1 Tanks x $80.00 S <br /> P PLAN CHECK (installation or Repair) <br /> � PLAN CHECK FEE - %W7" each SUBMISSION/RESUBMISSION - - g�q.C'O <br /> REPAIR - ---- - -- ----. ---.. <br /> ---------------- -- -- <br /> P, TANK REPAIR FEE = 1110.00 each TANK �! Tanks 0110.00 1 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, einiAuA one hour to be paid on plan submittal) <br /> jR UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION i SAMPLING INSPECTION <br /> When applicable) Wien applicable) (vhen applicable) <br /> FEE = 130.00/hr FEE _ $35.00/hr FEE $35.00/hr t <br /> TOTAL DUE 1 /73 8•o0 <br /> OFFICE USE ONLY <br /> F.11.001 RAVW11111 <br /> ,SWEEPS IIQ9IM,,DE DIST �CODE I�AMOUNT DUE AMOU � CH c �Af51N11i19PuRlflpVb"a1uDIY DATE RECEIVED ' <br /> „IT I <br /> MI��^�aNl@R�j <br /> 17,38 1 <br /> �� t�t Rei 1�r,�u �f��lll1 PiP �RiIRIIIIRVIl9R f l i!18RIIIIRIIIIIPliI RIP ix! OR.n9�iiR��flllm!I IIIR�IR dR�RRRRp I� .,. �R IRB�RIIRIR9 IRVRIV. I�IIMRRIRI(�1'JR �9P I IRVIMIT <br />