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SAN IRAQUIN LOCAL HEALTH DIORICT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> iFl FACILITY/SITE-NAME FACILITY CONTACT NAME <br /> 'A ' <br /> VAA-.PYhf). <br /> SITE PHONE I WITH AREA coot <br /> L STREET ADDRESS <br /> S <br /> STATE IIPC W # of Tanks 1. <br /> Y CITY at Site <br /> ';TE <br /> .. ............. APPLICANT CONTACT NAME <br /> A APPLICANT/BILLING NAME <br /> P <br /> P <br /> L WITH AREA COPE <br /> I MAILING ADDRESS APPLICANT PHONE <br /> Typi <br /> -I- <br /> A STATE CODE TYPE of APPLICATION <br /> N CITY CLOSURE, 1149TALILATIOM ETC. <br /> T C-K <br /> FACILITY FEE $100.00 each SITE ADDRESS per YEARAL <br /> ............... <br /> A <br /> C 1986 1987 1988 1989 R E C F- <br /> I V I-D <br /> T <br /> V ------- <br /> E TANK FEE $50.00 each TANK ...........-V ..... ........... <br /> F 11-I..anks x50.04 1 1. .. ............... 1985 1987 1988 1983 ENVIRON <br /> HELI - <br /> A (multiply Ii fee for <br /> C each Year applicable) --- <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x 156,00 1986 1987 11988 1989 <br /> Y (enter ijo-u-nt and year) <br /> ................. <br /> C PERMANENT CLOSURE (Removal Or Closure-in-place) <br /> L ........ 6'�) <br /> 0 CLOSURE FEE = S,30.00 each TANK Tanks_!__ x $90.00 3 <br /> U <br /> 1jT11111AR1 CLOSURE (only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tank5------ x $80.00 $ <br /> .................... <br /> P PLAN CHECK (Installation or Repair) <br /> ----- <br /> A <br /> HIPLAN CHECK FEE $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> P TANK REPAIR FEE = $110.00 each TANK .............. -$......... <br /> E-11.---.,.-.----...-.--... ----------------- ......... -------- <br /> P --..................... <br /> AFIPING REPAI..R/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) FEI(when applicable) (when applicable) ............................... <br /> .................. <br /> FEE30 00 1 F E E $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> imp 1910 %no MIM mi Wwn IM10111111 RMINISM0 609.1WE <br /> SWEEPS I Camp I LU C CODE DIST CODE AMOUNT DUE AMOUNT RCVDCHECK I/CASH RGVD BY DATE RECEIVED PERMIT I <br /> ... .........- ............................. ... <br /> 7::41...................... .......... <br /> MEMO 11111 111 !11111111 <br />