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SAN #AQUIN LOCAL HEALTH DI rICT RGROUND STORAGE TANK PROGRAM - FEE NORKSHEEi F FACILITY/SITE NAME FACILITY CONTACT NAME A I STREET ADDRESS - SITE PHONE t WITH CC 'T11'7 0/ -te � T 7(? Y CITY 7 STATE LIP CODE t of Tanks at Site A APPLICANT/BILLING NAME APPLICANT CONTA T NAME I MAILING ADDRESS APPLICANT PHONE t WITH AREA Cone 7? - - - - N CITY -- ATE 2IP CODE o PLICATION NHTALLAT ION. LTC. FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR 7 TOTAL A - - --- --- -— - — C 1986 1987 1988 1989 T I t V - - E TANK FEE _ $50.00 each TANK F t Tanks x $50.00 1986 1987 1988 1989 A (multiply-I-by fee for --- - - C each year applicable) f I ------- --- — — L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) I - --- -- T t Tanks x $56.00 1986 1987 1988 1989 Y (enter mount and year) — C PERMANENT CLOSURE (Removal or Closure-in-place) N-T S CLOSURE FEE = $90.00 each TANK - —CTanks x $90.00 f� R TEMPORARY CLOSURE (Only allowed one time for up to two years) C l E - ---------- - TEMPORARY CLOSURE FEE = $80.00 each TANK t an x $80.00 f � HEALTH P PLAN CHECK (Installation or Repair) PER L -- -- ---- -- A N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f - -REPAIR ---- _ --_ R TANK REPAIR FEE = $110.00 each TANK $ Tanks x $110.00 f E ----- ----- ----- ..---...------- - — P --- ------ — A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION (when applicable) (when applicable) (when applicable) FEE = $30.00/hr FEE = t35.00/hr� FEE = $35.00/hr f TOTAL DUE Is o'LQ 6 Ud OFFICE USE ONLY SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT t