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BAN 'OAQUIN LOCAL HEALTH DIRICT <br /> 4ERGROUND STORAGE TANK PROGRAM - FEE NORKSH <br /> F FACILI/TTY1ISITE NAME FACILITY CONTACT NAME <br /> C l-0 C o� � rC�I �QV C_ Qr Cy vQ <br /> L STREET ADDRESS SITE PHONE N (with Area Code) <br /> T <br /> Lcqo T lac { �v lov P09 93f 3a53., <br /> Y CITY C1 IP CODE N of TANK'S <br /> FAPPLICANT/BILLING <br /> + 0 t� �` SrC� C� at Site <br /> ME APPLICANT CONTACT NAME <br /> ¢,( IAPPLICANT PHONE N (with Area Code) <br /> 0 (061•e slO 0 �, 3 f 3 0// � S TEZIP CODE TYPE of APPLICATION <br /> Tz' � { �f�0$ (Closure, Installation, etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1981 1988 1989 <br /> V $ <br /> E TANK FEE _ $50.00 each TANK <br /> F N Tanks �_ x $50.00 1986 1987 1988 198'3 <br /> A (multiply-E by fee for <br /> C each year applicable) CV <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 oy applicahility) <br /> I <br /> T I Tanks �. _ x $56.00 1986 1987 1'388 1989 <br /> Y (enter 5mount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> O CLOSURE FEE _ $90.00 each TANK N Tanks x i90.00 $ <br /> 5 <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK N Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> R REPAIR <br /> EE TANK REPAIR FEE _ $110.00 each TANK N Tanks x f110.00 f ly'' <br /> A 14 <br /> I PIPING REPAIR/CLOSURE/REMOVAL (fees are per hour, minimum one hour to be paid on plan submittal ((PI CES <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING � ( <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL <br /> OFFICE USE ONLY <br /> SWEEPS N COMP Y LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK $/CASH RCVD BY DATE RECEIVED PERMIT I <br /> 5� � Pft 0 � /� lo/ Sfax OL• 5/J.OZ; (�.tii SI12 /6 `7 <br /> :1^ -` t.:.. .:.i .rr..u:.:+'ON: 4 A -.,'i:1ryK Pn _ _.N.:rig ._•� <br />