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• <br />SAN�AQUIN LOCAL HEALTH DIJRICT <br />uuncocDnudn emoeaC TAW ocnacAN - rEE unRRSNEE <br />F <br />... <br />FACILITY/SITE NAME <br />E <br />F <br />A <br />C <br />FACILITY CONTACT NAME <br />j}FIJnt <br />tea[ nY�i;�crl <br />r�r�•=T� <br />�- f�: <br />L <br />STREET ADDRESS <br />SITE PHONE I NTTN AR[ coo[ <br />T <br />Y <br />CITY <br />STAT <br />IIP CODE I of Tanks <br />e - at Site <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />I <br />MAILING ADDRESS <br />APPLICANT PHONE I NITN ARCA coop <br />T <br />A N <br />CITY <br />STAT <br />IIP CODE TYPE of APPLICATION <br />s Cl_0lURE� INtTAILATIONITC.�_�.,1,� <br />A <br />T <br />FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br />1986 1987 1988 1989 <br />E <br />F <br />A <br />C <br />TANK FEE 1 $50.00 each TANK <br />__ __ .__................._....____._ _ _._..___._.__ .._.......... ......___.___ <br />I Tanksx 150.00 1986 1981 1988 1989 <br />(aultipTy-1_ by fee for <br />each year applicable) _ $ <br />L <br />T <br />Y <br />STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br />I Tanks x $56.00 1986 1987 1988 1989 <br />(enter 3i666t and year) <br />...___ _ ._.....__.__.._._ __..._ <br />TEMPORARY CLOSURE (OnlyAllowed one time for up to two years) <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Closure -in-place) <br />O <br />__...___._._.___.._.-,_....___ . 00 e a c <br />- l'd <br />U...__. <br />R <br />...___ _ ._.....__.__.._._ __..._ <br />TEMPORARY CLOSURE (OnlyAllowed one time for up to two years) <br />E <br />TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $80.00 $ <br />..... <br />P <br />.._......I ... ....... <br />PLAN CHECK (Installation or Repair) <br />L_._.__......... <br />........... .................. ____-- <br />A <br />N <br />PLAN CHECK FEE=NM$30.00 each SUBMISSION/RESUBMISSION <br />... .............. <br />R,EPAIR— <br />P. TANK, REPAIR FEE = $110.00 each TANK I Tanks......x $110.00 -~ <br />E....,...____.__ ... .......... I._....._...__..._ ._.._ _._________ ___..._____...._.._ _...__._ ._.. ____.____.___._._......._...___..._._ <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 ISAMPLING INSPECTION <br />(when applicable) (when applicable) (when applicable) <br />--------- - --- ___._....................__.___„....._...__.._.._ . ..._...... _..._..,_._..___ ., .__ ..... ____. __. <br />FEE = $30.00/hr� FEE = $35.00/hrj FEE = $35.00/hr� <br />OFFICE USE MY <br />TOTAL DUE <br />$ <br />0 N1191111 <br />�!II'r,Tiifil111 . ��Nd �� PhI!�IIIII!�knill!iIR <br />SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT I <br />_.. ....................r.........._........._..................... ...... .................... ...................................... .... <br />.........._... — -- _ ____..__.._._..........._._.................._._...__......_. ___. _ <br />Zmnm92 m lnmm�ammn�mi mm�mrc� I�mDimil <br />