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® SAN 4WQUIN LOCAL HEALTH DISOICT <br /> '4 r <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> (F FACtLIt�Y/SITE NAME _ FACILITY CONTACT NAME <br /> 'M� NAM <br /> I <br /> TP.EET ADDRESS SITE PHONE 1 WITH AREA CODE <br /> Y CITY STATE ZIP CODE 1 of Tanks <br /> ��-_5gb at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> F <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> N CITY _ STATE ZIP CODE TYPE of <br /> T - y7-� C.�-rry-� - /'iy. LOBUR IHSTALLATIO . ETC. <br /> Im FACILITY FEES= $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1981 1988 1989 <br /> T <br /> I S <br /> E TANK FEE = 550.00 each TANK <br /> F 1 Tanks , �x 550.00 - 1986 1987 1988 19813 ! �O ^ _ <br /> A (multipTy f by fee for ---- — <br /> G each year applicable) �� $ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I -- - _ <br /> T 1 Tanks J x $56.00 1986 1987 1988 1989 I q q D <br /> Y (enter imount and year) <br /> 108 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = _$90.00 each TANK _ 1 Tanks_ x$ 90.00 f <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 1 Tanks _ x $80.00 8 <br /> P PLAN CHECK (Installation or Repair) <br /> A - <br /> III PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION <br /> I..._T'P,EPAIR <br /> R TANK REPAIR, FEE = $110.00 each TANK 1 Tanks x $110.00 5 <br /> E <br /> A PIPING REPAIR./CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I _ <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION ab <br /> (when applicable) (when applicable) (when applicable) <br /> FEE=530.00/hr FEE = 535.00/hr FEE = $35.00/hr 47- (a S 2 3(9 2S <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> �,�.��glq�g4qq.��l i�gggq�.�l�lqq!qqqlll'.g9gP�qlqiqp�qq gggqqqqq�lq�lqqlqqqqqqqlqqq!I�@lgfllq 11q�q�gggqqqlqqqqllqliqqfq dgq�IlGllggqqqqiqi�llqq@gli�gglql�� igggqqliqqqq{qplqqqqqqqqql�! glgq�lgqqqqpa�il�l� <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT P.CVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> ll Qui635 d } 32 5 �' S ��� �� <br /> mmM gnu)agg1� imm q (�IMIM <br /> tm lglgliq� ggqqlila!qlqqllq q liggqq ggqqq�l ,c, l z�s ��ggql�Jq��qqll ggG�llqqlf�q@qqqlq l <br /> TV C�78>) <br /> I <br />