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SA A AQUIN LOCAL HEALTH ARICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET— <br /> F FACILITY/SIZE NAME ^— — — — � FACILITY CONTACT NAME <br /> SITE PHONE t WITH AREA CODE <br /> L STREET ADDRESS �� <br /> J _LS 2 <br /> Y CITY n STATE ZIP CODE 1 of Tanks 2 <br /> cI-Z o at $ <br /> ite _ <br /> APPLICANT CONTACT NAME <br /> A APPLICANT/BILLING <br /> 7 NAME -----~— —~ -- <br /> P _.._� . �C�� �(� l l r3 V4 <br /> L'""' _ —l APPLICANT HON t WITH AREA CODE <br /> 1 MAILING ADDRESS��OI (✓( tC —..___.___ <br /> �yl� �y.L_�..�L.L <br /> `^ STAT ZIP'COOE TYPE of APPLICATION <br /> N CITY cLOauRE, INETALLAT IDN, ETC. <br /> FACILITY FEE _ $100,00 each SITE ADDRESS per YEAR TOTAL <br /> _ _ _ _�,___,.,_._•,_ <br /> C 1986 1987 1988 1989 <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks __� x $50.00 1986 1987 1988 1989 q p <br /> A (mwltipty t by rem for �0 �� �_�� i oo $ moo <br /> C each year applicable) —� — — — <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH d SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks__ x $56.00 1986 1987 1988 1983 -- ]i <br /> — <br /> Y (enter amount and year) Es <br /> C PERMANENT CLOSURE (Removal or Closure-in-place)�� <br /> 0 CLOSURE FEE _ $30.00 each TANK A Tanksx $90.00 $ <br /> — <br /> P, TEMPORARY CLOSURE (Only allowed one time for up to two years) __ -- <br /> E -- ------ A tanks x $90.00 <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK ______ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> N PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR ----- <br /> P. TANK REPAIR FEE _ $110.00 each TANK t Tanksx $110.00 $ <br /> F -- <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 _ $35.00/hrZ FEE $35.00Ihr $ <br /> T _ <br /> — <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> G!.10;I!@.G�!IIGI�II!IGGflfGGGGG!!�G�9IAGIII�IPII.INGGIIGIG!GIIfIgIIG ISI!GN2GNGGG!IuG11GGGGCfu1,91GGIIGiG19GiIG1.!!1@GGGII�IGGG!GGIP.�GGI GIGG"alfdiG9�IGIIG!I!:fG1GGl@i �Gfl�^J'u�iGlilillG9li!IGGIIGGG9CV!I�:IGiIGIGIG!GG�II@. G@G.�'�iIGIGGIGIG@111!IMGI1GAGj' <br /> SWEEPS A COMP A LOC CODE 01ST CODE AMOUNT DUE AMOUNT RCVO CHECK A/CASH RCVD BY DATE RECEIVED PERMIT A — <br /> !.I ' V 'Ilm 9GIG!!P,I!1111GIlGGVGGPuIIIIGgI�GGIII!:II!IIIGGIGIGGGI!IGGIIIG!IGfdIG!I!G�IIIGIJiGNfGiGGIG19GIIGGiIiI IIGGiIIIIiIIIIGGGG9GIIGGIII!GC iGIIIGIIG9111GG119111•IGIIGGIIGIIGIIIGIGGGIIIIGGGGIIIIGGL IIIIIIIGWIGGIII!GIGIIVIGIGGGGGIIGGIh� <br />