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un84 JUAwU1,4 LuuAL HtALTH DISTRICT <br /> 'RGROUND STORAGE TANK PROGRAM - FEE WORKSHEL <br /> F CC <br /> FACILITY/SITE NAME —� <br /> A �a / FACILITY CONTACT NAME <br /> L STREET ADDRESS �� e < <br /> / SITE PHONE 1 YTTM ..c. coda <br /> T <br /> Y CITY �— <br /> �� STAT ZIP CODE 1 0l Tanks <br /> < / at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS <br /> C oa APPLICANT PHONE 1 WITH AREA coda <br /> N CITY <br /> STAT 11P CODE PPLICATION <br /> CLGmyma. TMmTALL^TIO". 9TC. <br /> FACILITY FEE = 4100.00 each SITE ADDRESS per YEAR <br /> A — TOTAL <br /> IC1986 1987 1988 <br /> 1989 <br /> V <br /> E TANK FEE = 450.00 each TANK <br /> F 1 Tanks _ 1 $50.00 1986 1987 1988 <br /> A (mullipfy I-by fee for 1989 �yfu <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = 456.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicabili y) <br /> I <br /> T 1 Tanks x 456.00 1986 19871988 <br /> Y (enter iiount and year) 1909 �� G <br /> C PERMANENT CLOSURE (Removal or Closure in-place) <br /> L �- <br /> 0 CLOSURE IEE = 490.00 each TANK 1 Tanks x $90.00 $ r� <br /> R TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $00.00 each TANK <br /> 1 Tanks 180.00 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = 430.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R TANK REPAIR FEE = 4110.00 each TANK <br /> P 1 Tank _ _ x 4110.00 S _ �-- <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 = 435.00/hr FEE = 435.00/hr <br /> t G?� <br /> DfFlCF USE ONLY TOTAL DUE <br /> FSWEEPS1 COMP 1 LOC CODE DISI CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVO BY777-- <br /> e i <br /> r m n9kmgl t <br />