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Q""% --UAYeU1v1 LUCAL HEALTH DI"' RICT <br /> 1,ERGROUND STORAGE TANK PROGRAM - FEE YORKSHED,/ <br /> f FACILITY/SITE NAME <br /> h FACILITY CONTACT NAME <br /> I GBiL �/f5 5 7/37ivn/ <br /> L STREET ADDRESS SITE PHONE 1 WITH •[[• cool <br /> 1 <br /> T <br /> Y CITY STAT IIP CODE 1 of Tanks <br /> ;GC��O at Site <br /> A APPLICANT/BILLING NAME <br /> APPLY CANT CONTACT NAME <br /> � <br /> IMAILING ADDRESS <br /> C APPLICANT PHONE 1 <br /> WITH am[• CDD[ <br /> Z Lf3GO <br /> N CITY IIP CODE TYPE of APPLICATION <br /> K /�N S C19 2069 nD.u.[. ,,,n.u.noY. [Te. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 190) 1988 1989 <br /> r 9G <br /> I <br /> v /Ou /oma /oo ioo /oo• $ Uc� <br /> E TANK FEE f 150.00 each TANK <br /> F 1 Tanks .5 1 $50.00 1906 <br /> I 1987 1988 1999 <br /> A Imultcply I-by lee for <br /> C each year applicable) 5� SG <br /> L STATE SURCHARGE = f5G.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25297 for applicability) <br /> T 1 Tanks „ x 156.00 1986 1987 1988 )909 <br /> Y (enyer amount and Year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks_ s $90.00 $ <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = 190.00 each TANK 1 Tanks 3 x $90.00 <br /> P PLAN CHECK (Installation or Repair) r <br /> L <br /> A <br /> N PLAN CHECK FEE _ (30.00 each SUBMISSION/RESUBMISSION <br /> f <br /> REPAIR <br /> R TANK REPAIR FEE = 11110.00 each TANK <br /> I I Tanks x $110.00 { <br /> P - _ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = (30.00/hr FEE _ $35.00/hr FEE =:S 35.00/hr <br /> { <br /> OFFICE OIE OILY TOTAL DUE <br /> i <br /> SWEEPS 1 COMP I LOC CODE DIST 7a,=7n <br /> AMOUNT RCVD CHECK I/CASH =RCV�OYDAIEVED PLRMIT t <br /> 3 � n in <br />