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Y " <br /> S AQU I N LOCAL HEALTH IWICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME ' FACILITY CONTACT NAMEPAYMENT"_ �- -- <br /> L STREET DDBES SITE PHONE Ik HITN AREA CaoE <br /> V" � l—' <br /> I � _�`.__..�..__ D c C i 5 1989 <br /> Y CITY eE] 2IPCDDE I« of TanksSAN J9 IQUIN COUNVC- �� � at Site PUBLIC ALTHSEPVICES <br /> ....._._.. .__..-.__._._,_ __ _---.-•-•EfW}#�4{ A i l ALIIyALILISI.�_.------_.... <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAVE <br /> P <br /> 5 <br /> L 1 <br /> +, <br /> I NAILING ADDRESS APPLICANT PHONE I WIT. AREA CODE <br /> N r,I� n STR <br /> T TE //�iIP7�N OD PPLIAATTN <br /> �` vb�'4j C40BURE INSTALLATION, ETC. <br /> .. _._--.__..._.......,......._..._.__.._._.__............v_._...__..,........,..........._.___.-_.._.,—------..._._.—_—...,..._._...._—_..__...—...._....... <br /> ...._.__..___ <br /> A FACILITY FEE $100.00$100,00 each SITE ADDRESS per YEAR TOTAL <br /> ......_._._._,_..,........._............._....._.._.,_...,_..._...,.._....._ <br /> C 1986 1987 1988 1989 <br /> T <br /> E TANK FEE = S50,00 each TANK - -- <br /> _._.,........•...._.. ....--._.__..-......__.... .. .... .... .. . <br /> F S Tanks x $50.00 1986 1987 1988 1989 <br /> A (multiply j-by fee for ..__...-----...._ --_----•--• <br /> C each year applicable) S `- <br /> L STATE SURCHARGE = 556,00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x 156,00 1986 1987 1988 1989-- — -----_ <br /> Y (enter a-a—Hk and year) - ...... .._._._._.._.__..____ --•_.._..___._.____�__ .._ ___ _�__ ____ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) - <br /> 0 CLOSUREA f. .........__......_.._..__, __._.....__. _.___......____.____._ ._.__._.__... _- - <br /> FEE $10,00 each TANK i Tanks---:� $90,00 S <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) _ <br /> E....___. _ .__._.. ._.._._._._..------------.___-------.-.__ -- <br /> TEMPORARY CLOSURE FEE = $80,00 each TANK I 11 Tanks x $80.00 S <br /> _....__......_..._.._._.__.. ._._-._.___ <br /> P PLAN CHECK (Installation or Repair) <br /> - �- -- <br /> L........_-_.._........._........................ _...._.....__- _...____-...._._._.. ..._... --------- --_ ._.._ ._.__--.-. <br /> IN PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION $ <br /> ...,.... ._.._.._..__._....................._._...._.. --__.._.__._..__.._.._. .._. <br /> kEPARi- IR <br /> S <br /> TANK REPAIR FEE+--$110.00 each TANKTanks x $110,00 <br /> --.-.-.__.----............_.._........-_......_.... ._. $__... ------ <br /> AIPIPING REPAIR/CLOSUREIREMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I ..........._._..._.__._.__-.._...._._......__..._...._-.._._.._-•---_._..._.._._...._...-.-.--.-_._..__._____.._..._____ <br /> IR UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> II (when applicable) (when applicable) (when applicable) <br /> _._..,_._..__.._._....._._ ------ - c <br /> FEE = $30.001hr FEE = $35.001hr FEE - $3.,,001hr S <br /> ........_..._.__........_..._._._.__...._...._.__.__...._.._..._........._-_...__ .._..___.__..._..----..___...__._._. ._....._...___.__.._._,._._.___.-__f..._............__...__.--..,____._..-..--.----____ _.-. <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> Ip �lll,l��!RIII !II?!'II!!I!lellll!i�ll�. !�`i�;, JRII!Ii�lln�l�lll P;irif CI!II!! gilIw, <br /> !ODUE AMOUNT RCVD HEC A/CASH RrVD DY DATE RECEIVED PERMIT t <br /> EEPS 1 COMP q LOl �OOE D[ST CODE AMOUNT <br /> c+ �f�tv �IWIE!�. .1I 1� ,, ;;'� I�III J IR!! SII(II!I!fi!@I�nIIII I�!�I!!Il lull! 9���GE!I!!!!!111!!I!Illsl!!ihllq�l��!'I��GII ! Ill!,li�lll l!Illlll!{! <br /> " fir' V f l" �.,, <br />