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SAN J (DUIN LOCAL HEALTH DISTRICT _ <br /> U ROUND STORAGE TANK PROGRAM - FEE WORKSHEET C, <br /> F FACeLITY/SITE NAME FACILITY CONTACT NAME <br /> L STRE T ADDRESS �n SITE PHONE t WITH AREA CODE <br /> Y CITY/00 <br /> STATE ZIP CODE 1 of Tanks <br /> — S�D C�� G1v — T— at Site <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L 0 C� <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> n1_ �i i^vayac Gi; . <br /> N CITY G v — TpT ZIP oC�ODE TYPE of APPLICATION <br /> T [\ CLOSURE, INSTALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 19871988 1989 — <br /> T _ <br /> E TANK FEE = $50.00 each TANK d $D <br /> F 1 Tanks .3_ z $50.00 1986 1981 1988 1989 <br /> A (multipTy 1-by fee for _ <br /> each year applicable) /SO — <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25281 for applicability) <br /> T 1 Tan" 3 z $56.00 1986 1987 1988 1989 <br /> Y (enter amount and year) _ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L----- — — <br /> O CLOSURE FEE = $90.00 each TANK 1 Tanks z $90.00 f <br /> S— <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 1 Tanks z $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L ----- <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR ------ <br /> R TANK REPAIR FEE = $110.00 each TANK — -----Ti Tanks z 1110.00 f <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 INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FE0/h <br /> E = 130.0r FEE = $35.00/hr f <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> NEW <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 4/CASH RCVD BY DATE RECEIVED PERMIT t <br /> odfi,01 �� / 4'c•c) �•S. 6 37 9u / 3G S,: <br />