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SANOOAQUIN LOCAL HEALTH D*RICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ......... i)l CNA T*Ti�C1 TAT-W. <br /> . I TZ <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C <br /> # —---X,U_ <br /> L STREET ADDRESS SITE PHONE W I TH AREAcoo i G 10 1990 <br /> I <br /> T ------ ------------ --------------- <br /> . . ENVIR <br /> Y CITY STATCODE of Tanks 5NMENTAL HEALTH <br /> S—ld ee� at Site /S VICES <br /> ........... <br /> A APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> P <br /> P OF <br /> I MAILING ADDRESS APPLIT('ANT PHONE I AREA COVE <br /> 7 <br /> A 176 <br /> N CITY P TE ZV'CODE ITYPE of APPLICATION <br /> T RE, INSTALLATION ETC <br /> ............ <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ............... .............. <br /> C 1986 1987 1988 1989 <br /> T -------- <br /> 1 <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> ............................................... ..................... --------------------- <br /> F # Tanksx 450.00 1986 1987 1988 1989 <br /> A (multipTi-i-by fee for <br /> C each year applicable) <br /> L STATE SURCHARGE $56.00 each TANK (see CA HEALTH t SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x 456.00 1986 1987 1988 1983 <br /> (enter iiNk and year) <br /> ................... —--------------- <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L ....... <br /> 0 CLOSURE FEE = $10.00 each TANK I Tanks x $90.00 <br /> S -------- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $80.00 <br /> .. <br /> ............... <br /> ................. <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> ------------------- <br /> ' <br /> R TANK REPAIR FEE = $110.00 each TANK <br /> E ......... ...... ................. Sx $110.00 S <br /> ......... <br /> P................. .......... <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> .............. <br /> FEE = $30.00/hr FEE = $35.00/hr FEE <br /> .......... <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> IRNM mmm 1111M M, M III to IMMON 1=11IMM WIMM =09M 011=11111111= <br /> SWEEPS R COMP # LOC CODE DIST CODE JMOUNT DUE AMOUNT RCVD( SH ASH RCVD BY DATE RECEIVED PERMIT I <br /> ........... ......................................I ............. .......... ...... ........... <br /> 3z 15"96q c <br /> /C 5 i 111MM <br />