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SAN NAQUIN LOCAL HEALTH Ell ICT <br /> iRGROUND STORAGE TANK PROGRAM FEE WORKSHEEW <br /> F FACILITY/Si-i-NAME—P FACILITY CONTACT NAME <br /> A <br /> C <br /> I WITH AR <br /> 'A IT IIACGDC <br /> L STREET ADDRESS SITE PHOME <br /> Y City DE I of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAIL ADDRESS APPLICANT PHONE I WITH AREA CC" <br /> N CITY�' CDE' TYPE of APPLICATION <br /> ETC <br /> INGTALLATIOM.CLORURt, <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C191 fli" Tiii , <br /> E TANK FEE e 150.00 each TANK <br /> F I Tanks x 150.00 1983 <br /> A (multiply"i-by Fee I <br /> C each year applifatil <br /> L STATE SURCHARGE e 156.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I I Tanks 1 156.00 1386 1381 1388 138? <br /> Y (enter ii6iit and year) <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE - 110.00 each TANK i I <br /> U ------- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE z $90.00 each TANK T I Tanks x 190.00 <br /> P PLAN CHECK (Installation or Repair) <br /> L - <br /> A <br /> 11 PLAN CHECK FEE = 130.00 each SUBRISSION/RESUBMISSICII <br /> REPAIR <br /> R TANK REPAIR FEE $110.00 each TANK 1 Tanks 1 $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 14SPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE 130 OOIhr EE 1 3 5.001h r FEE 135 0 0/-h-, <br /> TOTAL DUE I <br /> OFFICE us[ ONLY <br /> WEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT OUT AMOUNT RCVD C NEU 01 CASH r,'CVD By GATE PfCE1VED PE P.M IT I <br />