Laserfiche WebLink
SAI�,,aAQUIN LOCAL HEALTH D,2.*..,W <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> tF FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C _ C <br /> ISITE PHONE I"IT" ARCA CODE a <br /> SS <br /> L STREET ADOREQ 1 <br /> Y CITY STATE ZIP CODE t of Tanks <br /> ✓/" r�( � at Site fI <br /> A APPLICANT✓/BILLING NAME — -- — APPLICANT CONTACT NAME <br /> P <br /> P _ <br /> ds_tf__LgN�__-- <br /> L <br /> 1 MAILING ADDRESS- — — _--- APPLICANT PHONE t WITH AREA CODE <br /> ,,SppS N CITY STATE ZIP'CODE — —PPLiCATION <br /> / CIDEURE, INETAILATION, ETC. <br /> T <br /> Ise <br /> 1Pr✓ o <br /> _ X_[Q3Yr --------------� <br /> FACILITY FEE = $100,00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> T 1986 1987 — 1988 —1989 -- <br /> I <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks x (50,00 1986 1987 1988 1983 T_ <br /> A (EultipTy-1-by fee for <br /> C each year applicable) —� f <br /> I ----.. <br /> L STATE SURCHARGE = 156,00 each TANK (see CA HEALTH d SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x $56.00 1386 1981 1988 1989 <br /> Y (enter iiaunt and year) -— -- —-- <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) --- — — <br /> L - --_- — — ------------ -— --- -- - <br /> 0 CLOSURE FEE = $90.00 each TANK - t Tanks_1� x $?0.00 f D o <br /> S__ _..— --- — — — -- — <br /> U-- ------- ---— --- — — <br /> R TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> E _ — — ---- --— — — -- <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK �I Tanks -_ x $80.00 — t <br /> P PLAN CHECK (Installation or Repair) <br /> L - ----- --- --- ---.._ - ----------- --- — <br /> A <br /> �11 PLAN CHECK FEE _ $30.00 each SUBMIS5ION/RESUDMISSION is <br /> REPAIR — <br /> P, TANK REPAIR FEE = 1110.00 each TANK t Tanks x $110.00 $ <br /> - -- - <br /> p <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> - — --- --._.._. . ........ <br /> .. <br /> FEE = $30.00/hrf -- _- — FEE _ $35.00/hr r FEE = $35.00/hr f <br /> TOTAL DUE $ <br /> oFFFCF USE ONLY <br /> '@.@@V@@@@G69 II@9FI@.I"!I@@@Iq@���'1a�911fi1i@II@@@I 'Ni!Nei@!!�I@!iiiil�l@@�C6a;l@i�9C!Ilil!@1�1@";�@@I9n9d�1Pi!�@IP,I@'�@fdd;Q!I'til@9@ 'IiGI@il�il@I�@i!i!u'@Ill@iG„TuflT�l�.fl@II1���Cul@lEil�@If�i@@@@ <br /> 4EEPS I COMP 1 LOC CODE DIST CODE AMOUFIT DUE AMOUNT RCVO CHECK 1 ASH RCVD DY DATE RECETVED PEP.M[T i <br /> � <br /> ............ . .° 3 its/6 <br /> G IIIA IIIUi@.i. @f!!. <br />