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SANAOAQUIN LOCAL HEALTH D41TRICT <br />UNDERGROUND STORAGE TANK PROGRAM - FEE URRKSHFFT <br />F <br />A <br />FACILITY/SITE NAME <br />TOTAL <br />FACILITY CONTACT NAME <br />C <br />1 <br />A,41220 -r Z: <br />4-00 7 <br />L <br />I <br />STREET ADDRESS <br />SITE NE I WITH AREA CODE <br />T <br />F <br />A <br />C <br />I <br />I Tanks 1 150.00 <br />(sultipfil-by fee for <br />each year applicable) <br />Y <br />CITY STATE <br />ZIP CODE I of Tanks <br />at Site <br />AP <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />1 <br />C <br />MAI=S ADPL NT PH AREA Cape <br />A <br />N <br />CITY 1 AT <br />1IP*CODE TYPE of APPLICATION <br />'17", 'T <br />A <br />FACILITY FEE =-$100,00 each SITE ADDRESS per YEAR <br />TOTAL <br />C <br />1986 1987 1988 1989 <br />E <br />TANK FEE $50-00 each TANK <br />F <br />A <br />C <br />I <br />I Tanks 1 150.00 <br />(sultipfil-by fee for <br />each year applicable) <br />1986 1987 1988 1989 <br />S <br />L <br />STATE SURCHARGE = 156.00 each TANK <br />(see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br />T <br />Y <br />I Tanks 1 156.00 <br />(enter 44ifit and year) <br />1986 1987 1908 1983 <br />C PERMANENVCLOSURE (Removal or Closure -in-place) <br />L <br />0 CLOSURE FEE x $10-00 each TANK <br />S <br />U <br />9 TENPORARY,4,CLOSURE (Only allowed one time for up to two years) <br />E <br />TEMPORARY„CLOSURE FEE $80.00 each TANK <br />PLAN CHECK (installation or Repair) <br />PLAN CHECK FEE -- 130.00 each SUBMISSION/RESUBMISSION <br />I Tanks" x $90.00 <br />I Tanks__.- x 190.00 <br />REPAIR <br />P. TANK REPAJA FEE = 1110.00 each TANK s— x 1110.00 <br />E <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 SAMPLING INSPECTION <br />(when applicable) (when applicable) (when applicable) <br />FEE = 135.00/hr FEE= 135._00Zhjr <br />TOTAL DUE <br />OFFICE USE ONLY <br />SWEEPS I I COMP 1 !LOC CODEJ.DIST CODE. AMOUNT DUE I AMOUNT RCVD <br />—U ... . ...... . . . ...... I ...... <br />V7 . A M YA2A Ow 2111-- <br />M� <br />1/CASH RCVO DY.I DATE PECEIVED1 PERMIT I <br />