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0 <br />SAN ,IOAQ'U IW LOCAL. HEALTH D TR I CT <br />UNOER6ROUND STOPAGE TANK PR06RAM FEE MORKSHEE1 <br />[if] FACILITY/STTC NAitE~....--._.._.......�..-__......_.,._...�_..,..._.._._____...___...��_ FACILITY CONTACT NAME <br />C( ��!-� ELr✓ . �E!��% �L [, G�j`-'�'1-ice �_ ®t :,� ��i� 1-4 r t-1 <br />I <br />I�STREET ADDRESS, --T---• j51TE PRONE .# usrN AAiA CpGC <br />1'f CITY ��BT;YrTE 2T? r,G2E I t of Tanks <br />ij L -c> o i a; Site <br />APiAPPt1CANT/BliliNG N„NE. T^_ .-�.' -- • .--- -- - ^. AP°LTCAIiT- CONTACT itAttE.� '. <br />PUt3cFr- i I . �� •a--�.� �--rc- -� iG►��� r�.,a�-iz�l �s <br />LlI ffA[LIfiG ADDRESS_ _:..�._..__.._....__.._.._T..._.,.._......_._._-.._.. pFPITCANT PHONE 3 uzYM AREA COW._ <br />N CIiY r�STATE�rI IIO1'E -TYPE of APPLICATION _..._ <br />_! �.�.� �t-''�t✓►a"�f�.'--- ..__ ___.__ �3-.'.Ic�oaV�K, AXATALLAT90h. eca,_ <br />;FACILITY F£:,-.4i00,+?0 ea:h SITE ADDRESS Per ?EAR, <br />.Ai..._...__ .,_.-...._....-------_..�__�.. -._-1980 _....`... -- tGBi:_ .I ..•1988..._ _�. ...i989�..,._---�-----1V��G <br />TANK FEE�= 4s0.00 each TANK <br />__.._...._..__...........:..- ..-_:..•.....,-- -.._- _• --- ..:...._ ... <br />.._.__..:.... _ <br />..._-.,...I. <br />T Tanks _ x 450, to ! 1'06 l 1987 Joe � Icgy _,_. <br />ENVIRO P <br />(AultiPTy �-by fee for !-- _..�^. _-•.-----•-.__. i_.._.-_.__.-_. <br />,ea(h year ao7licabl?)-........-.-_�.__.--_._....._ <br />STATE SURCHARGE = 156.00 wh 'ANY (see CA HEMP SAFETY CODE Sec 252.97 f -or apol icabr f i;y) <br />I Tanks <br />.._........%_-,.. <br />iC,O------_....-.r_---iy8b '--T....-• 1987. ---- 1448 1:81 _.��T—.......__.—�.. <br />(enter a116unt a,,d Year) <br />TOTAL <br />al <br />tif I - - - - <br />Iva <br />,L HEALf <br />ICiPERMANENT <br />C'_OSLyF ;Reaovai .or CTasari*-in-Al a,,F�........___-_..._.__---_....._.__......�._------..____,_.._�____.��_�� <br />L. <br />IS <br />--- ..-..----.__..--- --- ---- ----- --- __. . _..._..__..._ :.._"-....... - _--------;_�..._,_.�...�r_.____ <br />CLOS091 FEE Tants --{ - x 194'GO, <br />each TANK—. <br />0 <br />F• <br />-rr`00.00 <br />F^_ _ .. _... .._.____._._... _� _4 <br />TWORARY CLOSURE (On Iy allowed one (loo for uD to tuo:yea rs) <br />—� <br />TM.ORARY CLOSUKI FEE 180.00 each TANK <br />i ranks a 4$0.08 <br />I.� <br />FtPlAff <br />CNECK.•.(lnstall3tion oC-repair) <br />rlhlf i{£r:K FEE - s.30.00 each SUB ISSlti4!RE i!Cf1faSI0!(_ <br />- - - - <br />4 _ <br />PEFAIri <br />! �I <br />TANI; REPAIR FEE - 1110,00'each TANK <br />- ' -r 4 i'dRis , x 4.1111).0;- <br />14 <br />PIPING REPAIRICLOSUPE/RE-10YALw(Fee5 are per ho::r, aWAOk.one ?,007 to 0 paid on plan submittal) <br />UNAUNORIIEO WEASE EJA'UATIJ:, <br />CO�a.R+J+,?fOtl INSP•CIIOtf <br />SAMPLING IIISPEC31:' <br />(When appltcable) <br />(ashen aPpIica5�le) <br />when applicable) <br />130.0^01iirl <br />f35:1^lhri <br />FEE =_f sr,GOlirt`..-,— <br />L..�FEE^ <br />..._..._._....._..__ <br />_fEE <br />,.._._.._.__........� <br />TOTAL DUE . <br />s <br />o ficf USf My <br />, <br />SNEEPS ICO" If LOCS� DIST ...COVE ..A`!OUNI DUE] AMOUNT RCVD CHM 11CA R;YO . <br />.DY DATE RECEIVED PEPMH I <br />L_ ....._ .._.__.....:.__.....:.._._._..:__ ...._.................. _ <br />r �yG 3 2r7 1300 ... I'�-........ _. <br />