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SAQUIN LOCAL HEALTH D, ICT <br /> WGROUND STORAGE TANK PROGRAM FEE WORKS <br /> ACILITY/SITE NAME rFACILITY CONTACT NAME <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA CODE <br /> I <br /> Czc�i) �FtacQ-FSCos/ -- <br /> YCITY STATE IIP CODE 1 of Tanks <br /> C(1 9SZD3 at Site / <br /> F APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> - �ETcr2- W P L LA-GE <br /> I MAILING AOBRESS APPLICANT PHONE 1 <br /> [. 1 MITM AREA CODE <br /> A — —_--- f V K _ _ —�2o i� ' I -F4 --+(005— <br /> N CITY STAT IF COD TYPE of APPLICATION <br /> T — — , p CLOSURE. INSTALLATION. ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS)p r YEAR — TOTAL <br /> A -- --- ------.--. --- - - - ------- <br /> T 1986 1987 1988 1983 IC QD <br /> .--- — —�00 --- 1 o� i Q s ---- <br /> E TANK FEE _ $50.00 each TANK, <br /> F t Tanks I x $50.00 _--- — 1986 — 1981 — 1988 1389 (Q q — <br /> A (multiply 1 by fee for ------. <br /> C each year applicable) 13� $ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CRE Sec 25287 for applicability) <br /> I —'J-- <br /> i f Tanks �_ x $56.00 1986 13871388 1383 C$ <br /> Y (enter zmount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — <br /> L ---- -- ----- — <br /> O CLOSURE FEE = $90.00 each TANK _ 1 Tanks z $90.00 <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, 1 Tanks x t80.00 f <br /> --- -------------- <br /> P PLAN CHECK (Installation or Repair) <br /> 'N PLAN CHECK FEE _ $30.00 each SUBNISSION/RESUBMISSION <br /> f <br /> REPAIR <br /> ------- --- <br /> R TANK, REPAIR FEE _ $110.00 each TANK 1 Tanks _ _ x $110.00 $ <br /> E -- <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 /> FEE = $30.00/hr -- FEE _ 135.00/hr FEE = 135.00/hr f <br /> TOTAL DUE $ 3�p e <br /> OFFICE USE ONLY — — `— <br /> IR!�(RRQIRD�MGVIIVRI I��AnnUll��llminlllAl�!II�Ip�9 ll���lmll�MIVfl �I�BDQIIV II�I�V��I�IIV��llll@Ifl�lll!'IIW��IIII�IIIIV��III�I��nVll611I0IfIU�ll�1!.IRl IIIiliTii ilili�IIII!�IIIIIIIVIIIBIf MIT nIII�I��O��VIVI�1��1���II�III��091�111@IVI�IIInll�ll�l�lll�ll���8. <br /> SNEERS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT P.CVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT t <br /> j 2,336 2336 Z �T � Lg7gp <br /> ePEI � b�'� ��' u�.�mmg�Imlls�I� lu ��uml �u��m � Ia�ll�uu!nnJ!p..na�l(su�l nulno ui!a MIM RA?1IMM1 TIME 11 nla����l���lul��lo.l�mnl��a���111MMMln���,u <br />