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1 <br /> SA 4 OAQUIN LOCAL HEALTH D WRICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE NORKSHEET <br /> F FACILITY/SITE/NNA,ME r FA IL TY CONTACT NAlIE • <br /> ✓I..0 <br /> L ST T RESS 5 PHON II TN,""�"^ a <br /> T � 1� /�� <br /> Y CITY ATE � �ODE t of Tanks Z <br /> at Site <br /> A APPLICANT/BILL 66 NAME- APPLICANT, CONTACT NAME <br /> P_ S 1A __ <br /> 1 MAILIj)G 11�ORE5S - - - - APP4fCAT PHONE f wrrN "Re" eooe <br /> f, s / _ > <br /> N CITY - —-- - --TIISTATE I -G E TYPE of APPLICATION <br /> T - -•--_ I �� /�-- CLOBUR[. INSTALLATION, LTC. - <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 1986 1981 1988 1589 _- <br /> V . -- --�_ - - _ _ <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks _ f1986 1987 1988 _ f 1989 <br /> A ( ultipTy_f_byy feeee for for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH f SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiouit and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place)--^ ---- -� <br /> 1.__.__..__--._._-._---------______,-_.._..-•___--- t Tanks Z� $90.00 f �- <br /> 9 CLOSURE FEE _ $90.00 each TANK — T _, <br /> g.- — <br /> U - ---_—_ <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK R Tanks _�s $80.00 $ <br /> T� -:__-.- <br /> P PLAN CHECK (Installation or Repair) - <br /> L- — ---- ---- -— _----- <br /> A $ <br /> IN PLAN CHECK FEE =-$30:00 each SUBMISSION/RESUEMISSI011 _ - - -- <br /> REPAIR <br /> R TANK REPAIR FEE _ $110,00 each TANK t Tanks __ z $110.00lb <br /> E p...-..---------._._.------.A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan s -- <br /> R WNAUTHORIIED 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/hrr f <br /> :_.__,.._.�_._.._.L.....____..___. _ TOTAL DUE - $ -' <br /> OFFICE USE ONLY <br /> !0 NIIG��GGGGIG�GG�GIAG�!IIS.I!GIGG91GIIfGGGIG'141GIIGIiG�JIG'iPJIINI NIIGGI�!�JGGC!iGii9�i�!GGf;liIIG119GIG!GGGI.�i�@GGGGGGGGG!!IGI!!IV1GiG18'1!GuilrV?fuG!i�IGCfiIIG&"11iGIGIaYI!Iii��IIGIIRII;iGifli!iGf.GIIGGGG!V?9GG!Ifilli111G!If9G�NIP IG9GGdl4�f�!GIGGI�JIGi!ill!GG!GGGGGj <br /> SWEEPS 1 COMP f LOC CODED[5! CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT t <br /> '��9�J 1!V T,i1 �I�glgjllj�JIGI M!GI!GG.1198iIGGVGIG,I�BGIillGll'� GIIIGGGGVGGIII!GGiI!!!IG!'Jh�!I�GIG' IIGgIGIG9�GiIIGi91 lii!r14VdIIIGGGGGIIIIGGI IIG!IGG!GIVGGIGGGI!9iV.II�GIGGII�GIIIIIIGGGIIIIGGGGI@4�I dGG!I V1fG! I�GIINIG IGGIGGIIu <br />