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4 <br /> r <br /> SAWOAQUIN LOCAL HEALTH OTRICT , <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> Ih(FACILITY/SITE NAME FACILITY CONTACT NAME y �~ <br /> I <br /> L STREET ADDRESS SITE PHONE I "T" AREA CODE <br /> I <br /> T ________.._____ .�. 1 I I Ca,C _ _ <br /> Y CITY STATE TIP CODE I of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME �•� � � <br /> P <br /> P <br /> L...__._.___.__._.._....... ._................ <br /> _......___._ <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> C <br /> N CITYS1ATE PC ODE <br /> T TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, ETC. <br /> .._......_..._..___._..__.__.___....___...____.__.____.._.-•-•---._...�..___---- ZI _.._._ <br /> FACILITY FEE - $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A_....._...._._._____......_..................__...__._..._.._...---...._............................. <br /> C 1986 1987 1988 <br /> T 1989 <br /> E TANK FEE - $50.00 each TANK <br /> ___.-_..................................._............_...._._ ._.__...._....._.._.............. ...-- -_._.._ _...__._. <br /> I Tanks x 150.00 1986 1987 1988 1983 <br /> A (multiply-t-by fee for ......_..... <br /> C each year applicable) $ " <br /> L STATE SURCHARGE = $56.00 each TANK-(see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x $56.00 1996 1997 1988 1989 <br /> Y (enter mount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE - $30.00 each TANK ry I Tanks _ x $90.00 $ <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E....... <br /> TEMPORARY CLOSURE FEE -- $80.00 each TANK �!" Y $9� 00 f C)Tanks s_�__ ��__ _ <br /> P PLAN CHECK (Installation or Repair) <br /> l.11 PLAN CHECK, FEE`�-$30.00 each SUBMISSION/RESUBMISSION _ PAYMENT $ <br /> ...... . <br /> _._..._._., ............ <br /> REPAIR 1gR9 <br /> _ ._..._..._...._._._._.__... .._.__ _._.._...______...._._______ ._____-_•-- N QV—ST-14 2 2 <br /> R TANK REPAIR FEE - $110.00 each TANK ._._ <br /> dIN�Q� <br /> .c ..T <br /> P...._...._.___.___..__....__.....___.__._ ...._._._.____.....__.._ ttER #®ltS1Q�3___,� <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum olvb'Oht'16-be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTIONy� SAMPLINGINSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> . _ .............._ <br /> FEE _ $30.00/h..-.r ____. _...._._......_....._..__....._.. <br /> FEE = $35.00/hr FEE = $35.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> �Iq`:ql�ggq�nl!gglq'rgggqqlqqqqqin�.n!N;lm�!Igfq!!�g9ulgq!�q11!!Iq!�Iq!! 1!h!glgllgnqqqqn!Igiil�iggqllCPi°liilggnilli91118ilglriqlql,�Igl!!IJggPu!191!!�Ib"Iqi�'��!q!!qq'allu!Igilpgq�!rggil!iq!q!.11i!liiigllq!ii'�°IPufilTl�.gl��llggnnqlfilq!Igilggilq!iqilq!!!q IIIgPigl!gf�i�glgJ!!qqnilq!!qi!qqq!!!�' <br /> Ij SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK IICASH RCVD DY DATE RECEIVED PERMIT I �I <br /> ................................ . ..........^...,..............,...._...... ...........0W0"*'1!;:1i1!11 <br /> _.._._........_...._._.-._....._ __ - a <br /> 7 -- L,�-`� �i'-- <br /> (� III.Gall..l�llgq19gggqqlqlCqq.lq;i:qlqn i!I�I!9'JiIflIIggL9lgllq9lqlqi!n i9!r19Pdg1g8�99gqqqql!qGllq!Lq!!ggliglllf1V99199q1!gdLlllll!glgllglqlqqlq9qqllqq9qllll!1919,!illll��, i I �. I� <br />