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SAN WAQUIN LOCAL HEALTH D#RICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> - - _--------------------- <br /> F FACILITY/SITE <br /> ----FIFACILITY/SITE NAME FACILITY CONTACT NAME <br /> C G-4 -LC") L-J,4 <br /> I --- —'-'---------- <br /> LSTREET ADDRESS SITE PHONE f WITH AREA CODE <br /> 1 42O t� kETTLf-;MAI-I L'4 e34 4523 <br /> IIP BE I of Tanks <br /> Y CITY I STATE C? <br /> _ CO at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P _ [2oBE<T �{ LEiz ASsc�. JEFF TaYLorZ <br /> L ----- -'------- ---.._...- '- - ...------ - - — <br /> 1 MAILING ADDRESS j-33-7 # APPLIC T H i WITH AREA CODE <br /> I-bk1 E �U/E ZI 1 (qty ��" '4CO3 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION 61jrl 1 ea <br /> ��� ETC.CLUEURE. INSTALLATION. <br /> T �S�--ITo '�.�5�25 ---�rJsy�i.I-HTf <br /> FACILITY FEE _ $100,00 each SITE ADDRESS per YEAR TOTAL, <br /> I11986 -_1987 - 1988 --$989 f <br /> E TANK FEE _ $50.00 each TANK <br /> ----......-.__...-- - -....... - <br /> A hultipTy <br /> -1-by fee for oa <br /> - --... .. -- -- -- --- <br /> C each year applicable) 150 $ I50- <br /> I '-- --- � - --- :--�— --— <br /> L STATE.SURCHARGE = $56.00 each TANK (see CA HEALTH 4 SAFETY CODE Sec 25281 for applicability) <br /> T I Tanks x $56.00 19861981 1988 1989 <br /> Y (enter ii6iint and year) - — --------- - -- -- �jQ <br /> C PERMANENTCLOSURE (Removal or Closure-in-place) — <br /> L '- --- - --- — - -- --._.....----- ------- -- <br /> 0 CLOSURE FEE- $90.00 each TANK i Tanks 3_ x $90.00 <br /> U ...--------- ---- '---- ---- --- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E- — -- = -- - ------- ------ — - ---- -- <br /> TEMPORARY CLOSURE FEE = 380.00 each TANK h Tanks x $80.00 f — <br /> IP PLAN CHECK <br /> (Installation -or Repair) <br /> L----- --- --- - -- --- ....- ----- - - - -- - -- <br /> A f 00 <br /> 1i PLAN CHECK FEE $30.00 each SUBMISSION/RESUBMISSION b e v■, --_ <br /> _ L� --- - <br /> � <br /> REPAIR --r---- <br /> P• TANK REPAIR FEE _ $110.00 each TANK <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hbU" 19�g1 ( bmittall <br /> R UNAUTHORIZED RELEASE EVALUATIONCONSTRUCTION INSPECTION SNMWETION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE 1 <br /> $3UFEE $35.00/h_ .00/hr FEE _ $35.00lhT _ r $ <br /> - --1 ' - - - - _ __- ------ -- ---- --'- <br /> TOTAL DUE s (o B 00 <br /> OFFICE USE ONLY <br /> �m Q" 9 1�11flfl9�T,9!� !19fl9fl91P�flGfli�!flPr4AN8Ti OMI, FA!flIOP�!�1 9 iNET,,0910910110Ifl@€�ST111 fl19GVI flEill fl!��fl0 fled i���Ik 1Cfl�afll@N!� <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCYD BY DATE RECEIVED PERMIT I <br /> y� Z o z �1�, 00 (64. 00! 4, ..p9N1PiPP, Q1flfl11�1119V1�,fl�AflRP I (ILII!flflll!0.011l�l�.�11ifl' IiVflllll QIP I flAnl Gill@ IUflR9fl .19�If�NflIIID�VII flflpP!II .Nflll f9i800�91N@IIQVIIPI6111M� tlSt V i / B" <br />