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SAN OAQU I Al LOCAL HEALTH DARICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C C-11 114ol (1c, /V/C/r- <br /> I <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> Y CITY STATE ZIP CODE I of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CORfAtT NAME <br /> P 40 <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> !TH <br /> A ....... -------- <br /> N CITY <br /> STATE ZIP'CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, ETC. <br /> ------------- ------- <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A .............. -------I............. ------------- <br /> C 1986 1387 1988 1989 <br /> T <br /> I <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanksx $50.00 1986 1387 1988 90 <br /> - -by fee for <br /> A (multiply ................. <br /> C C <br /> each year applicable) <br /> L STATE SURCHARGE = $56.00 ea!!� .-(see-(see- A Htk�H & SAFETY CODE Sec 25287 for applicability) <br /> .......... <br /> T11 Tanks x $56.00 11386 1987 ilea 1989 <br /> Y (enter ii655t and year) -------- <br /> C PERMANENT CLOSURE (Removal or �ure-i - ace) <br /> L- �i e- __­ <br /> 0 CLOSURE FEE = $10.00 each TANK I Tanks x $90.00 <br /> U <br /> I TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK T I Tanks x $00.00 <br /> P PLAN CHECK (installation or Repair) <br /> L ----------­-...... <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK I Tanks x $110.00 <br /> E ----—-------- ............................... .......... <br /> .........----------I------ <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 T SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.� FEE $35, FEE $ <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT ` NT RCVD EC 1/CASH RCVD BY DATE RECEIVED <br /> .......................... <br /> .................... ..........--------- <br /> 0 Icq In-3 0 3Ajh3 3�-/ 0 <br /> � <br /> 11 1?11:1981 11N.INIRINNP 1111, 111,11 HITIii IMP I(111411111;1011N%111t <br />