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AJOAQUIN LOCAL HEALTH O STRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME __---_—_—_- — -- - -- <br /> A _ FACILITY CONTACT NAME _ <br /> L STREET ADDRESS <br /> SI PHO E 1 "r*" AREA CODE <br /> Y CITY S 1 C00 1 of Tanks <br /> A APPLICANT/BILLING NAME — - --- a� at Site o2� <br /> P APPLICANT CONTACT NAME <br /> I MAILING ADDRESS -- - -'-`� ------- __-__--- <br /> A -�. -6 X ?W.P- -- A ICA PHON 1 WITH AREA coot <br /> N CITY <br /> TA P CODE P PPLICATION -- <br /> -• cLoaueE IN TALLATION, erc. <br /> FACILITY FEE _ {100.00 each SITE ADDRESS per YEAR- ^ <br /> __.-.-._.____..___------------- _ _ TOTAL <br /> i 1986 1987 1988 1589 <br /> V <br /> E TANK FEE = $50.00 each TANK f " <br /> F 1 Tanks x 1. fS'. 1986_ 1987 1988 <br /> A (multiply t'hy Tee for - 198'3 <br /> each year applicable) <br /> L STATE SURCHARGE - {56.00 each TANK (see CA �- <br /> I _-----.____--- - - HEALTH d SAFETY CODE Sec 25281 for applicability) <br /> i 1 Tanks x $56.00 1986 1987 <br /> Y (enter iiiiuit and year) _ 1988 1985 <br /> J.0LP�ERNANENT CLOSUP.E (Removal or Closure in place)0RE IEE _ {90,00 each TANK1 Tanks-- --RARY CLOSURE (Only allowed one tine for Up to two years)RARY CLOSURE FEE _ $80.00 each TANK -- <br /> 1 Tanks__...... x 190,00 <br /> f PLAN CHECK (Installation or Repair) ----- --- 1 ------ —— ---- <br /> -------------------------------- ------- <br /> 11 PIAN CHECK FEE—=- 730-00 each-SUBMISSION/kESUCMISS10t1 — -- -- --- -� <br /> kEPAIR <br /> P. ZANY, REPAIR FEE _ {110,00 each TANK ---- <br /> J 1 Tanks x $110,00 <br /> A PIPIN6 REPAID,/CLOSUP,E/REMOVAL (Fees are per hour, minimus one hour to be paid on plan submittal) <br /> I - - --- — --.. --- -- - - - -- ---------- d on p------- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> SAMPLING INSPECTION <br /> (when applicable) (When applicable) <br /> _.._.. -- (when applicable) - --- -- - - - — <br /> FEE _ $30.00/hr[ FEE _ {35.00/hrl <br /> _.--_..__._.__.......____.....—_.--- FEE _ $35.00/hr <br /> OFFICE USE ONLY TOTAL DUE <br /> f <br /> °�.gVGGG41�h1WIVIlI!�'UCGVGGC�UG9'IVUG!l1�Gl�i�Vl� G9!V9VGG�IVUCVUGa'VNUVCRU:"JIVEIU!V'1119UCGVU".;'s�UCIIOUJVRUIU!U1V!IWVVVVV'�IICVIiRC'dUGWIWiG!G:6C�11iUIlUail!G�"�UIIV!I"1ViPufIiGUV111CWIUlI'V96W!'fiIIUIIUQIG�!WN@ VNBICGUV.Cj <br /> SWEEPS 1 COMP 1 LOU CODE DIST <br /> E lllV Gf <br /> CODE AMOUNT DUE . <br /> AMOUNT RCVO WCIGHG'VEUDCVVKIINVIIIVUI1.VI�C'd'• I RCVO DY DATE RECEIVED <br /> _..... PERMIT t <br /> , . <br /> FI �l6V, <br /> IlIVIGV@VVCIIJIWVGIIWW IIIIUIU1VIIVI IVVG9 .VVI>Jl�lfpii�VVpBBICQVI'VBCBUIIi <br />