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SANG OAQUIN LOCAL HEALTH DOTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ATEFACILITY/SI <br /> NAME FACILITY CONTACT NAME <br /> C ___ <br /> I <br /> I STREET ADDRESS SITE PHONE # wlrw AREA cooE <br /> T- —`t..p_o_.o._. ._— _ a d� _ <br /> Y Cirr — o a 0 D <br /> S' _ [/Nca� 8 ATE TIP CODE 1 of Tanks <br /> _...__.. _-_..___...._. _—_.._.... —_ __. _ q5o�0►a at Site_ <br /> AA APPLICANT/BILLING NAME -- APPLICANT CONTACT NAME y - <br /> Pff <br /> . ..---------.._...-... <br /> ....._--_....... __— <br /> I MAILING AD <br /> C APPLICANT PHONE # wITN AREA CODE <br /> T CITY <br /> T T`[T� ZIP CODE TYPE of APPLICATION <br /> CLOSURE, INBTALLA ON. ETC <br /> FACILITY FEE - 1100.00 each SITE ADDRESS per YEAR ^- _ <br /> C TOTAL <br /> T 1986 1987 1988 1989 <br /> 1 <br /> V <br /> E TANK FEE = WAD each TANK <br /> F 1 Tanks _ x $50.00 1988 1989 <br /> 1986 1987 <br /> A (multiply-[_by fee for _.._. -- ----- .,._.-_ <br /> C each year applicable) _ 50 — <br /> L 0 <br /> 1 ...__ — J-O .. ..— 5 d ~ _ <br /> STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiount and year) - - _ <br /> �'�� <br /> C PERMANENT CLOSURE (Removal or Closure-in-place)--_ — -1-- — <br /> Lr _.____-•-- <br /> 00 <br /> URE FEE <br /> D CLOS = t90. each TANK 1 Tanks x 490.00 4 <br /> P, TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK --- <br /> # Tanks x 180.00 $ <br /> P PLAN CHECK (Installation or Repair) — -- _-_-- <br /> L -_..... <br /> -— <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUDMISSION $ <br /> REPAIR --------_- <br /> __-___...__----_.._.__ _--..._-------- <br /> _ <br /> R TANK P,EPAIR FEE _ $110.00 each TANK —• - - "-'"'- <br /> E-......... .._._....._._._.. # Tanks x 4110.00 $ <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 /> FEE _ $30.00/hr .._' _...-- -- -____.__......_...__......_. <br /> FEE = 135.00/hr FEE = 435.00/hrr_ $ <br /> _ 46(a '"-- <br /> OFFICE USE ONLY TOTAL DUE <br /> 8'mmAmmmmmmml!!Illml m�nml!pm!m!!�!Imp!mlm'Iq�9�9fimm�Allml'mlm�l4!�J�RG�S1!ImmBCfii9mdB9!INIm�1�lm'!!!11�,�IQmIIIGmIi!mll!ImN1118 ilia"ima7mJi�imiml�mlBfimmai!Ilml!111111"Ilrmflimm.lilmml1md�Gu!m!IF��mIG1V!mllm 1�m�m�I�mlmlNml!ilVim'a�imA.�' <br /> SWEEPS 1 COMP .# LOC CODE DIST CODE AMOUPIT DUE AMOUNT RCVO CHECK 1/CASH RCVD BY DATE RECEIVED PEP,MIT # <br /> ��n.,l��u���c , l�umlrlp���a .m,m!I�um�l „I,`ca�!�li ,lmm�muummuuu!I,um!m�,uuul,ummlmuuumluuulurl!, !uuuluunm�,mllmmmm uuumlmummlaull,m!Immmuu!uuuuuuuuuuuuuum .!Ilmm��lmlmuuumuuilualmml:�l <br />