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�32 <br /> l,k SANOOAQUI N LOCAL HEALTH D Oft I CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET _ <br /> F FACILITY/SITE NAMET� N FACILITY CONTACT NAME <br /> C I �- v J Y" <br /> IWITH AREA COCl <br /> STREET ADDRESS�,/ SITE PHONE t 0C) `cy M1 � <br /> r <br /> Y CITY J S T IIP CDOE/ I of Tanks <br /> 4U c d n j 0c� at Site <br /> A APPLICANTIBILLING NAME - APPLICANT <br /> fCONTACT <br /> f�NAME 1 <br /> P "/{F V <br /> �� �'... -----.._ _ <br /> I'MAILING ADDRESS APPLICANT PHONE I WITH AREA CCCe <br /> N CITZIP'CODE TYPE of Y <br /> r_ n� 1 --- APPLICATION <br /> T CLOG URE, INSTALLATION, ETC. <br /> !'n FACILITY FEE _ $100.00 each SITE ADDRESS ,per YEAR _— �— _ _--TOTAL -- <br /> A ._.--------- _ _ — <br /> C —1906 1987 1988 1501 <br /> T — <br /> I $ <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks —x $50.00 — 1986 1987 1988 1989 <br /> A (eultipfy f-by fee for — <br /> C each year applicable) $ ° <br /> L STATE SURCHARGE % $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I -- <br /> T I Tanks LL x 156.00 1986 1987 1988 1989 <br /> Y (enter arioFiit and year) _ -- -- — c <br /> t <br /> C PERMANENT CLOSURE (Removal or Closure-in-,place) <br /> CLOSUREMFEE _ $90.00 each TANK 1 Tanks <br /> z <br /> . $ 0.00 $ M. <br /> , <br /> U <br /> R TEMPORARY CLOSURE (Only ailoved one time for up to too years) <br /> TEMPORARY CLOSURE FEE ; $80.00 each TANK '[ I Tanks x $30.00 $ <br /> P PLAN CHECK (installation or Repair) R <br /> N PIAN CHECK FEE ; $30.00 each SUBMISSION/RESUCMjM6I $ <br /> REPAIR <br /> P, TANK REPAIR FEE = $110.00 each TANKI Tanks x !110.00 $ <br /> P <br /> A PIPING P.EPAIP./CLOSUREIREMOVAL (Fees are per hour, minimum one hour to be paid on plan Submittal) <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (vhen applicable) (vhen applicable) <br /> FEE - $30.00fhrT - FEE = umothrr� FEE - $35.00/hr <br /> _ _.L.. ._._..-- — <br /> TOTAL 'DUE $ , " <br /> OFFICE USE ORY <br /> PRINT <br /> „ �1gh".5NM <br /> i SWEEPS I COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> 12 <br /> t l�ry "� ► "'� !?,f N' !, . ., , Ell! lili! MR <br /> a' 1�'fiE ,I . -.. <br />