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SA*OAQUIN LOCAL HEALTH D f'RICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> I� FACILITY/SITE NAME ��''�,� (( FACILItY CONTACT NAME <br /> 1 --- ---tet e1��/ _ 'L rV P /0/11 ....... �Aar C�nl <br /> L STREET ADDRESS SITE PHONE 1 <br /> " WITH AREA CODE <br /> VE IIP CODE 11 of TanksY CITY <br /> ,� dC� oN at Site <br /> F APPLICANT/BILLING NAME APPLICANT CONTACT NAME ~ <br /> F + <br /> L.......-_ C. ._.._.�iv_w1r�NXYl .0 C�c3fn1 _ qN__ C06_E <br /> I MAILING ADDRESS J ` APPLICAN PHONE 1 NITN AREA CODE <br /> aII - -- 2 a�7h _.—�cvm- _ SC}- . 9I6 <br /> NJ CITY <br /> T � STATE IIP rppE PLICATION <br /> JOS CLOSURE NETALLATION. ETC. <br /> _---- -- <br /> FACILITY fEE = $100.00 each SITE er ADDRESS pYEAk TOTAL <br /> A ........._.- -__-_..........._..._.-'--'-__-._._._..........___....._.. _ ..._.._.... - ._.._.. - — ---..-_.__—._ _— <br /> C 1986 1987 1988 1989 <br /> --- —__�-- ---- A Y M <br /> t _------ ------- ----- <br /> E TANK FEE _ $50.00 each TANK -- <br /> _..-_..._..............._. --...-...- ..... ...__....-. _.._..-. � — — --- ---- ` _ 9 <br /> F 1 Tanks z $50,00 <br /> fo 1386 1987 -� 1988 -� 1983 -� <br /> A (nuRipiy-f-by fee for �..__...._... �.. ----------- ------------...._._.._..._..-- --^- - r---- ..__ <br /> C each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicabilijYJA4ITVSr, n F <br /> T1 Tanks z $56.00 1986 1987 1988 1393 <br /> Y (enter ii6li5t and year) <br /> — L <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) --- --— <br /> O CLOSURE FEE _ each ach TANK 1 Tanks 0.0 <br /> _ z (90 $ <br /> 5...—_—.._.-_._.._..00 ea U -- <br /> -- -- — <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E --- --- - -- _-_---_--- - ----.._ _. <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK, f .-Fan-L, <br /> s_____ z 490.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> — . ..._...__...._.. —...----- -.._......_--- — <br /> A <br /> III PLAN CHECK, FEE _ $30_00 each SUBMISSION/RESUBMISSION _ —- -- - $ <br /> ---. <br /> REPAIR — --- - <br /> R TANK REPAIR FEE _ $110.00 each TANK _ — -- — — — <br /> 1 Tanks z fi10.00 f <br /> P...._.- ..__._....__...._...._.-.. _ _ ..._ <br /> ------------------------ <br /> NG 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� FEE _ $35.00/hrf_,...--._._. <br /> _. .... .--_...................._............._.._.._._... <br /> TOTAL DUE f <br /> OFFICE USE ONLY - <br /> Mlp'.N!�@NNNNNNNNIiNI�IINN7n!I!NIS!N!I!�IIIIGN!�;N'IPflN!INIiN�INNVNiIINI!1IN7!!!�JNI!N!!Vi�191�1!IICPr,I"IiTIN!fNiNN1NiIIN'!!1NINNNII!IIIN1N!!191!!!I�NiNIflIIV�"'�aN1!I9,�INIiV111i�!11iNINl1i!fNiNllll!!I'lififliNllTi�l!VNINfiIN2NCV!if91iNIGiIN!IINIRII@ 9fflill!1Vi!91NVI!NN9iNVNN�fu1Vll! <br /> SWEEPS I COMP I LDC CODE OIST CODE AMOUNT DUE AMOUNT Rf,Vp CASH Rf,VO OY DATE RECEIVED PERMIT 1 <br /> t�AR2 <br /> ��I�Ib��fI�I�II3I�i��I���cl����INr999�NJ�r� !I�Nillll'IIRNIIq!II�NaII!NI911NI II?.I!I�NIIIII(nV191N9NIN"19NII!91T�INVN!11iNINNNNVIImIIillNdil iVVi19�IIIIN9VNINIINNIIVNflINII 16 VNP9Vu I iINI,gNIli1.191Nlllll!IW9JNGiigl!NVIIIIINNN�1!NfllmiNVi <br />