Laserfiche WebLink
SA*OAQUIN LOCAL HEALTH D ORICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> a (FiFACILITY/SIITE NAME —/— FACILITY CONTACT NAME <br /> f <br /> L STREET ADDRESS SITE PHONE A NIT" AREA CLUE <br /> I aro ; - - <br /> Y CITY 1 STAT ZIP CODE 1 of Tanks <br /> Sf Innr 1 at Site --- <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L—_ — <br /> I MAILINfi ADDRES� — APPLICANT PHONE 1 WITH AREA CODE <br /> A. D S 00 0 <br /> TCITY 0 STAT IIP"CODE TYPE of APPLICATION <br /> �2 CLOSURE. INBTALLAT[ON. ETC. C/O u <br /> ee <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> TA -- .... --- — ------ ---1589-- -- <br /> 1986 1987 — 1988 -- — <br /> V --- <br /> E TANK FEE _ $50.00 each TANK _ _ _ RECEIVED <br /> ........._.._ <br /> F t Tanks _ _ x $50.00 1986 1987 1988 1985 - <br /> A ( ultipry I by tee for <br /> C each year applicable) — �� f <br /> IP I'ONMENTAL HEALTh7 <br /> L STATE SURCHARGE = f56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25281 for a plicabil <br /> T t Tanks x $56.00 1986 1987 1988 1985 <br /> Y (enter iiount and year) — — <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L — ------- — — <br /> 0 CLOSURE FEE _ $90.00 each TANK <br /> S t Tanks__(___ x f90.00 f <br /> U —. <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E -- — — - <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK ---TA Tanks___ __ x (80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR ------ -- ----- <br /> P. TANK REPAIR FEE _ $110.00 each TANK — 1 Tanks x $110.00 f <br /> E--- <br /> ---- -----� ---- - —--- — — --— <br /> P ....----------- — ---- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hourp minimum one hour to be paid on plan submittal) <br /> I ----- — <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30`00/hrL — - -- FEE _ $35.00/hr — FEE -j$ <br /> 35.00/hr — — $ <br /> TOTAL DUE f G <br /> OFFICE USE ONLY <br /> PVVVV�BVI�III� 1V1i�Vlil �'��99�G�1i4.. VI�@VV Ba�VVVCGu"G96VN�mfJ i..�VVP�VRLVVI I VV1If3'611 V�fVIIVIta':VTufl�l . B��V!�V�VVMVVI�VINP ��IVIN��G�VVfu�V <br /> SWEEPS A COMP A LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CH CK ASH RCVO DY DATE RECEIVED <br /> PERMIT A <br /> - .__.............. ....... . ._......._...._ <br /> "gwal IVVVVJV IVIIVV@V�9.....IIIJf& �PII�1 ��P�yh <br />