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SAN &QUIN LOCAL HEALTH DI*ICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> if FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C �� � �iv� R.�l STAc�'�at,.1 � N1i�+4i MAfzT �RArt►c �R Jb�t�1 <br /> L STREET ADDRESS SITE PHONE 1 WITH Aram^ C009 ���� <br /> I I-1D5 MAxR ST• Z r>q - 838 -�16Z! <br /> Y CITY STATE—IIP CODE I of Tanks 3 19911 <br /> EScALIrd GA] "37-'� ..._ at Site 3 SAfy,/C,gQUIN i <br /> ..� H SE,I 'fCES <br /> AP APPLICANT/BILLING NAME APPLICANT CONTACT NAME ENVIRONMENTAL HEALTH AVISI(7N <br /> P KEN 1jA biu,2Nr i <br /> L __.. <br /> I MAILING ADDRESS APPLICANT PHONE I WITH .11C. oopc . <br /> C EQ�-l1 S PERS1-4rNG AVr ZD9 - ' 6Z.- 91`111 <br /> A _. �. --- _.. <br /> T CITY � STATE ZIP CODE TYPE of APPLICATION-T aY-T <br /> CL3 r.! _... __-- -�CA95�L _� x'9!6T PA.,K - <br /> FACILITY FEE = 1100.04 each SITE ADDRESS per YEAR TOTAL <br /> A .__._.__.___�_ _ _-- ___..._.. ,_ _....................__,.............__._._........_.__..._..._.__.... ......._ _...._ _._.... .-_ _.__.�..�_ _-- <br /> T 1986 -_-1987 1988 1589 _ <br /> I <br /> E TANK FEE $50.00 each TANK <br /> F I Tanksx 150.00 1986 1987 1988 1989 <br /> A fmultipTyl_by fee for - -- ----- -�•--� --- <br /> C each year applicable) s <br /> I — <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks_ x 156.00 1986 1987 1988 1489 - - <br /> ' Y (enter mount and Year) <br /> s <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE ■ 00.00 each TANK r 1 Tanks x 690.00 1 <br /> S <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E TEMPORARY CLOSURE FEE -- 180.00 each TANK 1iank_..._ <br /> s x 180,00 f <br /> P PLAN CHECK (installation or Repair) <br /> L __- _ -- -...__,._.__......_.---� __ __....._...,.........._-...... <br /> __....- <br /> A <br /> N PLAN CHECK FEE = 134.00 each SUBMISSEON/R£SUCMISSION 1 <br /> REPAIR -- REFI Ari Z" i <br /> R TANK REPAIR FEE = 1110.00 each TANK II Tanks I x 1110.00 1 <br /> _.....__......._....._......-.._......_......... <br /> _..__ ._...._. _._._.......__._._._— _T_—_ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.04/hr FEE = 135.00/hr FEE $35.001hr 1 <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> J II IP�9 GII�� VCS IGS , ' ' III NUM11=1111451 WINVIIJ '001=0 Iffloom Fj <br /> SWEEPS I COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH Rf'UD DY DATE RECEIVED PERMIT 1 <br /> ___. .. _. ._...._........ -................ I __..........._.... _..._........._. ........ _._.. ............ <br /> _. ...__. <br />