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aUAwUler LU4HL HEALTH DISTRICT <br /> ROUND STORAGE TANK PROGRAM - FEE YORKSHEL. <br /> F dAtILITY/SITE NAME FACILITY CONTACT NAME <br /> E -C�' <br /> I <br /> L STREET ADO ESS SITE PHONE 1 WITH AA[A eon[ <br /> T <br /> Y CITY STAT ZIP CODE I of Tanks <br /> j Q L Jjj at Site �— <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AA[A cone <br /> C <br /> A <br /> N CITY STATllP CODE TYPE of APPLICATION <br /> T CLUtlUA[. IM[TALLA1I004. [TC. <br /> FACILITY FEE = 4100.00 each SITE ADDRESS per YEAR TOTAL <br /> A--- <br /> C 1986 1987 1988 T 1989 <br /> T <br /> 1 t <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks 1 150.001986 1981 1988 1989 <br /> A (sultipTy 1 by fee for F — <br /> Ieach year applicable) t <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH N SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanksz (56.00 1986 1987 1988 1909 <br /> Y (enter iiia-$ and year) <br /> t <br /> EENT CLOSURE (Removal or Closure-in-place) <br /> E IEE = 190.00 each TANK 1 Tanks- 1 (90.00 4 _� <br /> ARY CLOSURE (Only allowed one time far up to two years) <br /> ARY CLOSURE FEE = $80.00 each TANK 1 Tanks 1 $80.00 S <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION t <br /> REPAIR <br /> R TANK REPAIR FEE = (110.00 each TANK 1 Tanks z t110.00 <br /> E 1 <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 /> IEE = t30.00/hr _ $ 50 EE t3j,00/hr <br /> 1 G <br /> DFflCF USE ONLY TOTAL DUE <br /> rI1lCOMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVO� I "i I I tlMIIIIXNIMIA IAI to ) i I it tlAIAIIIIIIIIIIA I ' r A gf IA�" II01 I' 'I Iii' I , , p��� <br /> '� ,r1YWYWYY0 WWIWIWIiN '��W^ <br />