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e SAN JCRQUIN LOCAL HEALTH DISACT <br /> __ _ _ <br /> UNDERGROUND STORAGE TANK PROGRAN - FEE WORKSHEET <br /> A FACILliY/SITE NAME - - -------- -__ _...-_-_-- <br /> d,� FACILITY CONTACT NAME -- <br /> L 'TT <br /> REE�SS -�ZI �T SITE PHONE 1T• vli �� ,��� � YITN ARIA Cpp[ <br /> Y Y 09 9'./ <br /> � � STATE ZIP CODE t of Tanks <br /> A APPLICANT/BILLING NAME '- -CA �� at Site Q��---� --- <br /> p — - <br /> p APPLICANT CONTACT NAME <br /> L AV11_ pLZ ---_ _ <br /> I MAILING ADDRESS -'- -------- P <br /> C APPLICANT PHONE 1 wlrN AREA coo[ <br /> N CITY <br /> 1 <br /> 7 1 ZIP CODE TYPE of APPLICATION <br /> cYPE Of rPLICATIOION. erc. <br /> - � <br /> E .. � <br /> AGILITY fE _ ;100,00 each SITE ADDRESS per YEAR - <br /> T 1986 --...___...__ TOTAL <br /> 1987 1988 1989 <br /> V - ---. f <br /> E TANK FEE = $50.00 each TANK L� <br /> .. <br /> F 1 Tanks x $50.00 -_- ,._. - .._.__. • -..._..- -_ -...-..-..-..� _- <br /> 1986 1387 1988 _..— .__-._... ....._ <br /> A (multiply-E—by fee for _ 1989 -` <br /> each year applicable) - -- <br /> L S1ATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I - <br /> Y (entersii666txand year) 1986 -- 1981- — 1988- 1983-- <br /> .._._ _ � f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) _ -^'---- <br /> L . -_. <br /> D CLOSURE FEE _ $90,00 each TANKIs �— 1 Tanks x (30.00 _ <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 !80,00- f <br /> P PLAN CHECK (Installation or Repair) — ----� -�- - --•- <br /> L... -_ - <br /> N PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> P. TANK, P.EPAIR FEE _ $110.00 each TANK <br /> ---- <br /> E.._._.__ _ _...__._.__.__._.._ 1 Tanksx $110.00 f <br /> 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/hr _ <br /> FEE <br /> _. _..._._._.,.._�_ -TOTAL DUE $ <br /> OFFICE USE ONLY <br /> IjIP@m�p9P991!II�IPIIPPIP91!!99911 �119999999f9Pl�pI. �IRI� J@PPiIPP1911PG��iOIpPIPIiIIPPl1I":! IPPPII!IPP9�!!191!!ICPI!8!"il!Ifi11n4911111IIPiGI!��P11iAl�l� ,GiPI!ILII!?I!;iliiGlilllPif11�118�Cu!iQIGiIIIPIIPI�I� p�Gll!��PIVIPP�!!�G!P�Ir�GB! ' <br /> SWEEPS $ COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT I <br /> _........_...._..._......._.....—.__ <br /> �•�iil�p�9.. . m: : rI��IryIImIP:P : ,!�191!IINflI@9P9!� 19!!gPPI�!!19A9!191Ph11!ImIPII�P�If!�!I!"��Pllm�!II�PmI'��fP���l!II�IP ���IIII�G99PIII�II�I�IIIC9 IPPI�If1�9�pPP91V <br /> �IIPflI11�919111999�919P9911VP.91 .V!IIII�IfiAi1!1�9!InI�NI�q�IP!:J <br />