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SAN aAQLIIN LOCAL -HEALTH D`. +"RICT 5 <br /> UNDERGROUND STORAGE TANK PROGRAM • FEE VDRKSHEET <br /> F FACILITY/SITE NAME .',i FACILiTf CONTACT NAME <br /> C <br /> L STREET ADDRESS <br /> t SITE PHONE 1 WITH AR[A COG[ <br /> STATE : ; .ZIP CODE # �',of Tanks <br /> Y CITY at:ASite 3 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME ', { <br /> P <br /> .Dam'C MCC AJPJ <br /> I MAILING ADDRESS APPLICANT PHONE # NIrN ANSA cote <br /> ' �3 t • uJ f,G,� ,� a oa - �G 3 <br /> A <br /> N CITY , TAT=IP-CODE TYPE of APPLICATION <br /> CM.O[VRl. [N[TALLATafOM, ETC. <br /> e <br /> FACILITY FEE = $100,00 each SITE ADDRESS per YEAR _ s TOTAL <br /> A - <br /> C1986 1981 M 1988 1989 <br /> S77 �. S'v SO S $ s`Z o a <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanks --_—Y $50,00 - - �.^1986 1987 �, 1988 � 1983 �. <br /> A (suitipi'y-f-by fee for -- -- <br /> C <br /> --- <br /> C each year applicable) A <br /> I ---- -- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH t SAFETY CODE'Sec 25287 for''applicability) <br /> T # Tanks �x $56,00 1986 1987 q 1988 1989 :3 ' <br /> Y (enter asof►At and year) 1411 <br /> --- <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90,00 each TANK # Tanks---I--,x $30.00 f <br /> U _._._ <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E TEMPORARY CLOSURE FEE _ $80,00 each TANK # T -may pfjl WT bo $ <br /> P PLAN CHECK (installation or Repair) <br /> L <br /> A SEP <br /> N PLAN CHECK FEE = $30,00 each SUBMISSION/RESUBMISSION <br /> REPAIR ply <br /> R TANK REPAIR FEE = $110110..00 each TANK # Tanks_ _ x $110.00 $ ;I <br /> E - ------- <br /> P <br /> A PIPING REPAIR/CL05UREIREMOVAL (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) w (when applicable) - <br /> FEE - 130.001hr FEE - $35.00/hr FEE = $35.001hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> :I <br /> A. .L UE::.II o. I LSI.i !''� ,: .,'a i INTJININIIAgimli 1,01 ROOMl I x d <br /> Ir <br /> ...... ..._._._...... WASH. RCVD BY DATE RECEIVED PERMIT $ <br /> .. .......__.._..._..._... _ __ _. _ _.�...._----.... <br /> SLEEPS # CORP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #IC,,� _U 5 � �U <br /> ..........._. _.. _............_........._.. ._ .._.._.__...__._._..._....._..... b.9 y 6, 5 a.L, <br /> II�Icry�I ��}6 <br /> WRIT V� �r� !I� ��1 , ,, 1 MI.119I�IIII 1. :, , ! ISI i,h �I i� i J <br />