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SA*OAQUIN LOCAL HEALTH TRICT <br /> UNDERGkOUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F�FACILITY/SITE NAME _--------. .• _. _ . <br /> IA �e _ FACILITY CONTACT'NAME <br /> L STREET� ADDRESS SITE PHONE # uITNAREA caoe <br /> Y CITY _._ a0�! <br /> _1 �/ STAT .IIP CODE_ # of Tanks <br /> ....-...`_ !�}�Z a p� at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME _- <br /> P <br /> F' <br /> L _._._. <br /> I MAILING ADDRESS APPLICANT PHONE # NITN AREA covE <br /> I; <br /> A <br /> T CITY ETYPE.g_f_A_PPLIC_'_______— <br /> C <br /> STATE IIP'CODE ATION <br /> ... E, INITALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR -"- <br /> q..,.,......_ ..._w_.._... ..._._...... �_ ., TOTAL <br /> T 1986 1937 1988 1989 <br /> /00-- /00— /00 ___.. /0() <br /> E TANK FEE = $50.00 each TANK - <br /> F # Tanks _ z $50.00 1986 1981 1988 1989 <br /> A (multiply V by fee for <br /> C each year applicable) - --" -- ----- ---- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I< SAFETY CODE Sec 25281 for applicability) <br /> T # Tanksx 156.00 1986 1981 1988 1989 - <br /> Y (enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) � �-.__— �— <br /> 0 CLOSURE FEE = $90.00 each TANKS. # Tanks <br /> P, TEMPORARY CLOSURE (Only allowed one timeforto two years) "-' --------__ <br /> E-.. ._� - `_.___.__._. _-_ _ . . <br /> TEMPORARYCLOSUREFEE xV $80.00 each TANK ._. _. # Tanks _ x-$80.00 -- �� <br /> iP PLAN CHECK (installation or Repair) ---�-- <br /> L <br /> A <br /> III PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION T <br /> P, TANK REPAIR FEE = $110,00 each TANK .s,� __o _..0_ <br /> E-...-......_..._.,_.....__.___.._.._..._._._..._._...._..._.�.,.._____---_.--..._..._- # Tanksx $110.0 $ <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 /> )vhen applicable) (when applicable) (when applicable) <br /> FEE _ $30.00 hr - <br /> FEE = $35.00/hr <br /> ..-..-.-............._..,.__..._ FEE = f35.00/hr $ . <br /> TOTAI:-DQE <br /> OFFICE USE ONLY <br /> p� @ptt <br /> ii. IN% In, FBI"I M. 119111 MIT! ,Ap .117111[I li grllnll I ,,.,IN. „ i a MIN ji114NpIi�Nllllllllllli9 ,pillfll11 ilIT0,li�lil Z <br /> 11111$i�lfll 1 <br /> 13NINiIISCII�NI�III;;IiNmitiIAlINM11� <br /> . .,.........-....................................................._.........,.,_..............................................._,.....AMOUNT DUE AMOUNT RCVD CHECK #/CASH Rr,VD DYE RECEIVEDPEP.MIT e <br /> SWEEPS R COMP A LOC CODE D[ST CODE AMO.._..........................._......__ ...._,.__...._.....__.._._»,.- _.._ . _..... ..itiliu�,loplill �I��II�ii��l�lllIl a+ <br />