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SAN ,44,dAQUIN LOCAL HEALTH eDIIAPfRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET PAYMFNT <br /> IF FACILITY/SITE NAME — FACILITY CONTACT NAM ECEIVE D <br /> A'�F�c DEC 2 8 1989 <br /> STREET A DRESS SITE PHONE I wITHSANA360X0UINCOUNTY <br /> I 5' '- // 7-// ST XLTH SERVICES <br /> Y CITYSAE iIP CODE f of Tagj4jCR' j�pkENT <br /> 7-19L 3?(o at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P � 2Rf/� ���/srr7✓ _✓rick /�ir'r �- �A cQy� Git2/s r��s�-�.l <br /> 1 MAILING ADDRESS ^� APPLICANT PHO I WITH AREA CODE <br /> C /ao E �i2�Arvtoa✓r Sr _ dog— -6eL o7`jp <br /> N CITY ,/ S}T�TE i1P CODE ,PLICATION <br /> T S�G v��/ , _-- L!w oeuRc. HerAllAr[oN. ere. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ---..� —---- <br /> T —1986 1987 1988 1989 <br /> /Pd JGJd f L4�. <br /> ------- ---------- <br /> E TANK FEE = 150.00 each TANK <br /> F I Tanks x 150.00 1986 1981 19881989 <br /> A (multiply t-by tee for --- � J S� <br /> each year appluable) J f , <br /> L STATE SURCHARGE = t56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25281 for applicability) <br /> I _ <br /> T I Tanks x 156.00 1986 1987 1908 1989 <br /> Y (enter aao nt and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — ^ <br /> L ---- — <br /> S CLOSURE FEE E $90.00 each TANK — I Tanks x $20.00 — f <br /> — Z__ - <br /> U -- /�F <br /> P. TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks_—_ x t80.00— f <br /> P PLAN CHECK (Installation or Repair) -- —-- <br /> L ---------- — <br /> A ---- — ------- -- <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> — REPAIR -- -- — ---- -- — — --- — <br /> P. TANK. REPAIR FEE = 1110.00 each TANK t Tanks x $110.00 1 <br /> E --- <br /> A PIPING REPAID./CLOSUP,E/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IIISPECTION — <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr — FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ("S - 7 � c) <br /> iG . . 9fJ�9NTapP9 91�9�9RNGS�aP I�'IIMGCw°G�9 X19 . 71V��GM9Uul�!N�elliVI �J IuG l6!G uGGIVIi !Cd�GI aGGligl� �1GVG 4flV!�r pC969a1i �J! I G4�C��118C0.� <br /> S0EEP5 1 LOMP 1 LO CODE DIST CODE AMOU)II DUE AMOUNT RCVD HECK /CASH RCVD BY DATE RECEIVED PERMIT t <br /> --- �7� 11 T;7 <br /> X89�qI 1116��C,� VGP��PGGGV"�I GIG "� Gl l�d�ll@! G191GJilG G9" CGGGG IG�GfGgIIG JI��J Gg9BlGGJIGV��GIIIGIG " <br /> E 1 i 3i'FEV Lu �� <br />