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�'IGS33 <br /> SAADJOAQUIN LOCAL HEALTH DISTRICT <br /> v <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FI FACILITY/SITE NAME — — FACILITY CONTACT NAME — <br /> A �/"" <br /> Awx/ <br /> L STREET ADDRESSSITE PHONE t WITH ARCA CODE <br /> Y CITY ST TE IIP CODE t of Tanks <br /> _ Tu—l�e �/S -6 at Site <br /> AP APPLICANT/BILLING NAME —� APPLICANT CONTACT NAME — <br /> P <br /> I MAILING ADDRESS — APPLICANT PHONE t WITH AREA CODE <br /> �O dox Z3 _ <br /> N CITY — (.� l/�ST�nT ZIP'CODE TYPE of APPLICATION <br /> _T c�DeuRE, INYTALLATIDN. ETC. 61 0 <* E <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR -- TOTAL <br /> A -- — — ---- — — <br /> C 1986 1987 1988 1989 <br /> V -- — — <br /> —--- <br /> E TANK FEE _ $50.00 each TANK �/V� a� <br /> F tTanks _ _ z (50.00 1986 1981 1988 <br /> A (multiply ( by fee for <br /> C each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec <br /> I 2 o1' ability) <br /> — ---- — <br /> T 1 Tanks x $56.00 1986 1987 1988 1 69r <br /> Y (enter iiHht and year) <br /> — <br /> PERMANENT CLOSURE (Removal or Closure-in-place) ---- ----— <br /> L..----.-- -- — -- — ——_ ---- — <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks / x $00.00 f <br /> U ._ _— — <br /> P, TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E -------------- --- -- -- — <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) —T — <br /> L..._.. ------ -- -- -- — -- ----------- — <br /> A <br /> N PLAN CHECK FEE _ $30,00 each SUBMISSIONAESUDMISSION f <br /> REPAIR ""---•----- -----.... <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x $110.00 f <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I --..--...------- -- --- — __ _ <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION — <br /> (when applicable) (when applicable) (when applicable) <br /> _ _....._..._,. ........_--...__.—._._.._ ..... -----— ..._ — — — -- — <br /> FEE = $30 60; FEE _ $35.00/hr FEE $35.00/hr f <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> ZING G9G ISG PW WIGIBMGG@IG�G!�GG ..IM911t 1 JG IigCGGGf�I M@III��g IV 4�Nmjr � �9,1CI�MG@ <br /> SWEEPS 1 COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO HECK /CASH Rr,VD DY DATE RECEIVED PERMIT t h <br /> 10111111 uuu�ul �uu�a lu�I w luuuuu��lu lm I —11 , uuaull I��uum'uu� �uul 110;nwuluou1 M. <br />