Laserfiche WebLink
S A I rOAQUIN LOCAL HEALTH E TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C LOf,(-rd 7-D LAD P L_L_ <br /> I szcc 10 ec-CiD k 1) <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> IaD9 - <br /> T (T\KKE, I <br /> Y CITY STATE ZIP CODE 1# of Tanks <br /> OQ_ at Site Q�E <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P fkc' Dslby� 'TMbLiSTf_AC-S TfdL KE0 R06LCI ET <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> N CITY ST ZLP'C DIE A <br /> ('04 <br /> T '��v bcc�b CLOSURE ETC. <br /> FACILITY FEE $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ............... <br /> C 1986 1937 1988 1589 <br /> T <br /> V <br /> 1 <br /> E TANK FEE $50.00 each TANK <br /> F I Tanksx $50.00 198b 1987 1988 1989 <br /> A ( uItipTy__1_by fee for <br /> C each year applicable) — <br /> I so s <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter a-m-55rt and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK x $90.00 <br /> U <br /> 1jT1MP11A1Y CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x $30.00 <br /> JV7 <br /> P PLAN CHECK (Installation or Repair) V E:D <br /> L <br /> A S E P 2a <br /> 19�� f - <br /> IN PLAN CHECK FEE = $30,00 each SUBMISSION/RESUBMISSION <br /> REPAIR rAL HEALTH <br /> R TANK REPAIR FEE = $110.00 each TANK _ ITanks x $110.00 <br /> 7--7 <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 /> FEE $30.00/hr FEE = $35.00/hr FEE = $35.00/hr 1 $ <br /> TOTAL DUE Is <br /> OFFICE USE ONLY <br /> M" WWOR " I I I <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD ��Er V <br /> RCVD BY DATE RECEIVED PERMIT 9 <br /> .....................-..................... ............ ............. <br /> p il= <br /> 11 — �__ A <br /> 11 Zjjg.i� . <br /> Amull "j� , 17 <br /> I MEET, IN H In .I . 143110U.1�1 ITIR 11.111 1 MWER <br />