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N <br />t t <br />SAN IAQUIN LOCAL HEALTH DIS RICT <br />uMnFOADnuNn RTAPARF TANS PRnARAN - FFF NORKSHFFT <br />... .... _...... ._........_... __...__..... .... __._..-._._._ <br />F FACILITY/SITE NAME <br />A <br />FACILITY CONTACT NAME <br />each SITE ADDRESS per YEAR TOTAL <br />_. __ _.___._____.....____... _.__.__......_,..___....................._....__.....____ <br />1986 1987 1988 1989 <br />f <br />V- <br />L STREET ADDRESS SITE PHONE t VITN AecA cooq+'s 1 0 1990 <br />G^% h-xio <br />1....__ _ _ ____.._. <br />Y CITYSTAT <br />,)'Td ck w <br />E CODE 1 of TanksYI M TM <br />at Site PERM <br />A APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />i� Peri <br />L....._ _..__._.._._..... _ _.____....__ .�_-•_ _---__.___._ <br />,11 ..2"' w -f <br />I MAILING ADDRESS ,1 n/ <br />wtT� mmsA Does <br />APPL ANT PHONE 1 L <br />N CITY <br />T......_._.._.___�� _.____.___ __ _ _. _ <br />�SSTT9T IIP'CODI. TYPE of APPLICATION a <br />._lC..j� _ co.00uas0 rtn�tr►L�,eTcos, ETC. <br />._. <br />A........_._..._.__...._........_ <br />C <br />T <br />1 <br />....... .__-_-_.-.__............... .._._..____...____� <br />FACILITY FEE = $100.00 <br />.............._.......__._.._._ <br />each SITE ADDRESS per YEAR TOTAL <br />_. __ _.___._____.....____... _.__.__......_,..___....................._....__.....____ <br />1986 1987 1988 1989 <br />f <br />V- <br />_..__ _ .____....__. <br />_ __ _._.._._...__-.___ <br />U............. <br />R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br /># Tanks_ _ x $80.00 _ <br />f <br />E <br />TANK FEE _ $50.00 each <br />TANK <br />F <br />A <br />...._ ..... ._............................. <br /># Tanksx 150.00 <br />(multipTy_ 1 -by fee for <br />..___........___...__ ...____.___._._ ___ .__.. _ __ <br />1986 1987 1988 1989 <br />-'-- <br />C. <br />I <br />each year applicable) <br />L <br />STATE SURCHARGE = $56.00 <br />each TANK (see CA HEALTH It SAFETY CODE <br />Sec 25287 for applicability) <br />T <br />Y <br />1 Tanks x (56.00 <br />(enter iiount and year) <br />1986 w 1987 1988 1989 <br />---* - ---- -- ~— ---- <br />$ <br />__..... ..... ___.... _.. __ __ .. _ _. _. _ . <br />C PERMANENT CLOSURE (Removal or Closure -in-place) <br />L ...__.__._.._._._._._......_.. .... ... __._..._....... _ <br />0 CLOSURE FEE _ $90.00 each TANK <br />#Tanksx $90.00 <br />- <br />f <br />S <br />U............. <br />R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br /># Tanks_ _ x $80.00 _ <br />f <br />P PLAN CHECK (Installation or Repair) <br />L..........__._..._......_...._ . ........... ..... __.. <br />A <br />N PLAN CHECK FEE _ $30.00 each SUBMISSIONAESUDMISSION f <br />R TANK REPAIR FEE = $110.00 each TANK I#Tanks x $110.00 f <br />E------ <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/h ._......_................._...-......._..._..__.__....._......__....__........_._...._..._....___._._._._._.._...._..__...__..._....____.._.__._..._..__....__.......�._._..._._. <br />r FEE _ $35.04/hr FEE - $35.00/hr f <br />_.........._........_..........................__........._._._...._._ ........ _ ...._........__....._............ --_..... ... _ ...... ......... ......... <br />._.__..._ _.....__._._ ._....._... _ <br />TOTAL DUE $ <br />OFFICE USE ONLY <br />MM <br />SWEEPS # COMP # LOC CODE DIST CODE MOUNT DUE AMOUNT RCVD CHECK ASN RCVaY DATE RkGE <br />Ido •(S�zff <br />