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bAN JUA1 UI-k LUCAL HEALTH DISTRICT <br /> ERBROUND STORAGE TANK PROGRAM - FEE NORKSH <br /> FFACILITY/SITE NAME <br /> ' r CFACILITY CONT CT NAME <br /> C1 C�� �F� . ` tJ� , Tom . - Q I-461J WARTF-R <br /> L STREET ADDRESS SITE PHONE t (with Area Code) <br /> T I� say �T�i � Ic k�E�� ,�� , ao - 539 - 73 a3 <br /> Y CITY S TATE ZIP CODE t of TANK'S <br /> R 95 302 0 at Site 3 <br /> P APPLICANT/BILLING NAME APPLICANT HARD NAME <br /> L �E-yy,I � ��C H!`RD p1 LTD N) <br /> I MAILINGADDRESS APPLICANT PHONE t (with Area Code) <br /> A t,-2- W, I <br /> N CITY STATE IIP CODE TYPE of APPLICATION <br /> T 1 Ylo OE-S 7D erg q�3s l (Closure, Installation, etc.) CI,aSo I L <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 f <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks x $50.00 1986 1987 1988 1989 <br /> A (aultipTy-I-by fee for <br /> C each year applicable) f <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> I - <br /> Tt Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter anount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L �p{ <br /> O CLOSURE FEE _ $90.00 each TANK t Tanks <br /> 5 _,3_ x $90.00 $ a7 O. CC) <br /> U y, <br /> P, TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK t Tanks x 180.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R' <br /> EE ,fANK REPAIR FEE _ $110.00 each TANK t Tanks _ x $110.00 f <br /> A <br /> 1 PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr f <br /> TOTAL DUE Is Z7D <br /> OFFICE USE ONLY <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t CASH RCVO BY DATE RECEIVED PERMIT t <br /> 16SD G e6 32(0 <br />