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SANO)OAQUIN LOCAL HEALTH D*R <br /> ICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> VACILITY/SITE NAME FACILITY CONTACT NAME <br /> G <br /> I - — -_ <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> I eg —F3g ;?,705— <br /> T _--.-----•---------- .2o? <br /> Y CITY ST TE ZIP CODE I ttof Tanks PAYMENT <br /> c k46 rl a Site <br /> .112, RECEIVED <br /> P A APPLICANTIBILLING NAME 'APPLICANT CONTACT NAME <br /> Qy <br /> P Morric, Ali G <br /> I MAILING ADDRES.% ' APPLICANT PHONE I wir" A10EENWONMENTAL HEALTH <br /> 1 r PERMITISERVICES <br /> A <br /> N CITY ifi TYPE of <br /> T CLOGURE, IMBTALL.ATION, ETC. <br /> ............. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> A ....... ................ -­------- ................. <br /> C 1937 1988 1989 -1919- <br /> T <br /> AUG 1989 <br /> V <br /> E TANK FEE $50.00 each TANK <br /> E. .... ............ <br /> F I Tanks x $50.00 1986 1987 1988 1989 PE MIT SERVICES <br /> R <br /> A (#ultipTy_Fby fee for <br /> C each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH t SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks / x $56.00 1986 1987 1909 1989 <br /> Y (enter amount and year) <br /> C PERMANENT CLOSURE (Remoyal or Closure-in-place) <br /> L.............. —--------- <br /> 0 CLOSURE FEE 90.00 each TANK Tanks x I90.1)9 <br /> S <br /> U <br /> 2 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 <br /> ...................................................... <br /> P PLAN CHECK (Installation or Repair) <br /> L­­­-........................ <br /> A <br /> N PLAN CHECK FEE z $30.00 each SUBMISSION/RESUBMISSION <br /> ........................... <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK $110.00 <br /> —--------------------------------- .............................. <br /> P <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 SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> .......... <br /> F-EE $30.00/h r FEE = $35 00/h FEE-= $,3,5J.0 ................ <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> NIRM111ilfflill IT110�Iilqppiill 112ZI HF, <br /> SWEEPS COMP I LOC CODE DIST COD AMOUNT DUE AMOUNT RCV< CHECK CASH RGVD BY DATE RECEIVED PERMIT' 'I' <br /> ..................... ............ ....... ....................... <br /> 0 39 2,5 9-0-2,1 <br /> Hir, <br /> ,r1l <br /> 0", RITE 1 121 ri�1 41 I'lIE.P.I;[I I IIS <br />