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SAN gQUIN LOCAL HEALTH DIST?ICT <br />U�RGROUND STORAGE TANK PROGRAM - FEE WORKSHEET--.,, <br />f FACILITY/SITE NAME <br />TOTAL <br />FACILITY CONTACT NAME <br />j-.J_ree�ms— <br />E TANK FEE = f5 .00 each TANK <br />Qozzano <br />F t Tanks x $50.00 1986 1987 1988 <br />A (ultipfy'I_by tee for <br />I each applicable.)Pd. '------------ ------ <br />roeer <br />_eTaCk <br />L STREET ADDRESS <br />` oo <br />SITE PHONE t WITH AREA CODE <br />668 <br />r <br />Y CITY <br />—__931_ <br />ZIP CODE 1 of Tanks <br />at Site <br />A APPLICANT/BILLING NAME <br />1987 <br />APPLICANT CONTACT NAME <br />P <br />F <br />N <br />------ <br />A PIPING REPAIR/CLOSURE/REMOVAL <br />I-_ <br />(Fees are per hour, minimum one <br />I MAILING ADDRESS <br />APPLICANT PHONE 1 WITH AREA coot <br />F <br />- <br />-- -- <br />SAMPLING INSPECTION <br />(when applicable) <br />N CITY <br />ZIP CODE TYPE of APPLICATION <br />T -- --- _-- <br />- <br />_-- CLOSURE, INSTALLATION, ETC. - <br />FACILITY FEE =_ $100_00 each SITE ADDRESS per YEAR <br />TOTAL <br />A <br />/` CQ OL 0. j!� 1986- --198 1988-- <br />—_ -- <br />E TANK FEE = f5 .00 each TANK <br />f <br />F t Tanks x $50.00 1986 1987 1988 <br />A (ultipfy'I_by tee for <br />I each applicable.)Pd. '------------ ------ <br />1989 <br />------- <br />year <br />I'— -- --- --- <br />f <br />L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec <br />25287 for applicability) <br />T 1 Tanks x $56.00 <br />Y (enter iii5ht and year) p 1 <br />1986 <br />1987 <br />1988 <br />1989 <br />-- <br />------ <br />C PERMANENT CLOSURE (Removal or Closure -in-place) — - - <br />- <br />L- - ---- ------------ - -- .- __ <br />—_ -- <br />0 CLOSURE FEE = 190.00 each TANK t Tanks_7 x f90.00 <br />f <br />Tanks x 610.00 <br />$ <br />--- -- <br />P. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />TEMPORARY CLOSURE FEE = $80.00 each TANK, —�1Tanks____ _ x $90_00 <br />f <br />PLAN CHECK (Installation or Repair) <br />PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br />---- <br />REPAIR <br />- <br />--- --. <br />—_ -- <br />R <br />P, TANK REPAIR FEE = 1110.00 each <br />TANK1 <br />Tanks x 610.00 <br />$ <br />--- -- <br />p.... --- ---- <br />-- ---- -- <br />------ <br />A PIPING REPAIR/CLOSURE/REMOVAL <br />I-_ <br />(Fees are per hour, minimum one <br />hour to be paid on plan submittal) <br />------------ <br />R UNAUTHORIZED RELEASE EVALUATION <br />- <br />CONSTRUCTION INSPECTION <br />- <br />-- -- <br />SAMPLING INSPECTION <br />(when applicable) <br />(when applicable) <br />(when applicable) <br />FEE = 130.00/hr <br />_.._._..___—. _._..- _.__-- <br />--__—I-------._.._.-- <br />FEE = 135.00/hrr <br />FEE = $35.00/hr <br />�__.._ <br />- <br />$ <br />TOTAL DUE <br />f p o 0 <br />OFFICE USE ONLY <br />SWEEPS 1 I COMP i ILOC CODE DIST CODE AMOUNT BUE AMOUIIT 11111 CHECK 1/CASH RCVD BY DATE RECEIVED <br />REF 419 - 90 9b Z+IZ6 4........1) H 3 <br />PERMIT 1 <br />