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SAN IVAQUIN LOCAL HEALTH DIerICT <br /> ' UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> TY/SITE NAME L' -1 FACILITY CONTACT NAME <br /> F FACILIYZ <br /> CQ� Unnt� 1� � bJtDl <br /> 1S SITE PHONE Y (with Area Code) <br /> L STREET ADDRESS <br /> I <br /> T STATE ZIP CODE Y of TANK'S <br /> Y CITY 1 (i� �t��, Cf SZ (C at Site <br /> c�-D L <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME\ <br /> P t La vv D a � � � i � �'>r+�• tJ <br /> L APPLICANT PHONE $ (with Area Code) <br /> I MAILING ADDRESSZ p 9 —,33 j k 5-r <br /> C 3q ) c C' ✓aL1v K 0j a alb <br /> A STATE ZIP CODE TYPE of APPLICATION <br /> N CITY 5 Z 2 ) (Closure, Installation, etc. <br /> T �C' FJW� � G Cts <br /> M <br /> FFACILITYFEEE = 5100.00 each SITEADDRESS per YEAR <br /> 1986 1987 1988(Sb (SZSC�$50.00 each TANK_ z 150.001986 19871988 i by fee for applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK. (see CA HEALTH 6 SAFETY CODE Sec 25281 <br /> I I 1'6 1987 1388 <br /> T $ Tanks____ z $56.00 <br /> Y (enter amount and year) — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> O CLOSURE FEE = $90.00 each TANK $ Tanks-_� x $90.00 $ d <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> EI Tanks z $80.00 $ <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK ----- <br /> PLAN CHECK (Installation or Repair) <br /> L <br /> A $ <br /> /RESUBMISSION <br /> 11 PLAN CHECK FEE = $ MISSION <br /> R <br /> EPAIR <br /> R i Tanks_____ 110.00 $ <br /> E TANK <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to he paid on plan submittal <br /> R SAMPLING <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMLINGINSPECTION <br /> (when applicable) INSPECTION <br /> SD <br /> FEE = $30.00/hr FEE = $35.00/li1FEE _ $35.00/hr $ <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> SWEEPS $ COMP $ LOC CODE DIST CODE AMOUNT DUE AMOUNT kC'VO CHEC' /CASH RCVD BYDATE RECEIVED PERMIT 1 <br /> McC Da- 7 /`j �aSz 2 <br />