Laserfiche WebLink
SAN 't4AGTUIN LOCAL HEALTH DI,.AICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET P AY M ENT <br /> --- —-- RR 4.a1 <br /> F FACILITY/SITE NAME FACILITY CONTACT MAM <br /> C AUG <br /> 1 - <br /> L STREET ADDRESS SITE PHONE i WITH AREAcoos <br /> [ �41 5�- _ ENVIRONMENTALHEALTi� <br /> Y CITY �IgAT IIP CODE i of Tanks (/ <br /> at Site �'r <br /> A APPLICANT/BILLING NAME — APPLICANT CONTACT NAME <br /> I MAILING ADDRESS APPLICANT PHONE i WITH AREA CODE <br /> r 2 <br /> . ( <br /> A '— t`— --- — — <br /> T CITY —^ --_— -- — STA____ -- _ PPLICATfON <br /> S {./ y� O� LOEYREr [RETALLATI OR, ETC. <br /> FACILITY FEE _ $1`000..00 each SITE ADDRESS per YEAR O 0 A <br /> T 1986 1987 1988 1989 <br /> I _..__ — /ov 100 /ods $300 <br /> E TANK FEE _ $50_00 each TANK ! —/p0'lr, 1,�99_ Soo'"- '??Y300 Q O -- <br /> F f Tanks Lf 1 $50.00 1986 1987 1988 1989 <br /> A (multiply 1-by fee for --- <br /> C each year applicable) 1 a00 1 aoU_ A00 <br /> _ I IS &O <br /> I — — <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> I — -- <br /> T 1 Tanks 1 $56.00 1986 1981 1988 1989 <br /> Y (enter aiouot and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L — ------- -- — --- <br /> 0 CLOSURE FEE = $90.00 each TANK — i Tanks 1 190.00 is <br /> S_ —_... __._—------ <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 — i Tanks— 1 $80.00 f <br /> P PLAN CHECK (Installation or Repair) — <br /> L - ----- — — -- --- — -- ------ ---- 1 S <br /> A <br /> M PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUDMISSION f <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK t Tanks1 $110.00 f <br /> E-.._...___-------- _—........ --........—....._.._.._....__ _ _ -- _ _—_ —... <br /> P — —— .— ------ —.. <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I-- —_...------ -- — <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr f <br /> TOTAL DUE f 00 <br /> OFFICE USE ONLY <br /> GSWEEPS I COMP I� LOC CODE DIST CODE AMOUNT DUE AMOUNT RCCVD GI CHECK ICAiSH�iRICI�VZ111' DTEfl/P.CEIVEOu! EPIM�GT�I �r fl <br /> IFI J p� <br /> fl�f19IIfll,Ipq�Ip �ll!IIGNII�IiflflGa„ flPfl�Ilp IflII II��GGflGllfl!fGiGG!tIIflGGG'I lflf�III IIIIIiIG G!!iGCGIIGGVG1GIIGGIIfl II�GP!GV!GlGflflflflfli.IGIIGGM�GIGIIIfl fl^G.flGII II flIVgI IGGi11GAGIIGINIF11mG6 ll� <br />