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SAMOAQU I N LOCAL HEALTH DOR I CT Y M <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET R F.G E I V E D <br /> F�FACILITY/SITE NAME -- FACILITY CONTACT NAME J U L 'n ' 1990 <br /> EWM <br /> r, Ut�1®c�Al�- � IC �S"�ATtdN (,015 i NDS SINI��I <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA CODE <br /> 1 (7e1 r-_- AN LANA <br /> T Zo`�)qH� -�r1�� <br /> --- <br /> Y CITY La D` STATE ZIP CODE J # of Tanks <br /> 4) t Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P IZOIF, N . LSE:,- ASS 06-- -— .J °HN 6019U- gOPN <br /> I MAILING ADDRESS _ APPLICANT PHONE 1 WITH AREA CODE <br /> A � a 0 �Cz�PU�. ISN D IN 64 c;12.�(Z'?..___ 41 S) 4 61 --`3 u 9 0 <br /> N CITY p STA E ZIP'COOE TYPE of APPLICATION <br /> 1L�.��9-'- CIOBURl. INSTALLATION, ETC. 4�Q6U <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR +TOTAL <br /> A ......_....___._____._ ____. ___.__..�___.---_____._..__._...__ ___.._..__....__..__...._-•_---___.-................ <br /> __.__ <br /> T 1986_ _— 1981 1988 -- —158'3 10)0)(L) — <br /> I f _ ( a0 <br /> v- _ _... — __ ___ — `_ _ ------ <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks x $50.00 1586 198T 1988 1989 (9 Cj O <br /> A (nultipTy- by fee for — _.. __ —.._.---- _—...__.— --- -----i <br /> C each year applicable) 2 p $ Z <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25281 for .applicability) <br /> T 1 Tanks 4 x $56.00 1986 1981 1988 1989 <br /> Y (enter af-ount and year) ---- <br /> C <br /> ---C PERMANENT CLOSURE (Removal or Closure-in-place) - <br /> 0 CLOSURE FEE = $90.00 each TANK i Tanks � x $90.00 <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_ 1 Tanks x Q0.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L ��_____.__---•-_-.—._ _ ___.__.___—___.— __.___._.___.__..... _ <br /> A <br /> �N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> RiTA;K REPAIR FEE _ $110.00 each TANKT1 Tanks x $110.00 $ <br /> c ------ <br /> A PIPIF6 REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimuv one hour to be paid on plan submittal) <br /> I <br /> R UNAUTI.ORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = :30.00/hr FEE = $35.00/hr FEE = $35.00/hr <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> WMA E .. IG�IGgGBi�IG!�G. IGGGG�'GuGIGG1�iGIIGGGIGGIGIGi IiIuGG!1!IIG�Ga>'uG!1!!IG IV7GiGIf111G!�G!IGII;i!IGGIGGiGIG!GG9GIG1!�iiGGIGIG(Gh 'I �iGGGG�! <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> i. ....._....--- - ._....._....._..........-- ._..._.............._ ..............................._._......................._.._..._.....- .__._............. —me — <br /> I <br /> ! @GIIG GGGIP,E�JGMUD IMU <br /> nGG �GGIGGGG9GG!! GGGGG!IlG GIG!GGGG!�G9GIIG�RG !1 <br /> 1 <br />