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.+nlw JUAWU1,4 LU4:AL HL-ALTH DISI'RICI- —T lanyS <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> I FACILITY/SITE NAME fACILIiY CONTACT NAME <br /> a- <br /> LrSTREETDDRESS1 SITE PHONE I WITH AREA CODE <br /> Y STAT IIP CODE 1 of Tanks <br /> r _ at Site <br /> A APPLICANT/BILLING NAME PAYMENT APPLICANT CONTACT NAME <br /> P RECEIVED <br /> L <br /> I MAILING ADDRESS MAR 2 0 19 9 0 APPLICANT PHONE 1 <br /> C WITH AREA CODE <br /> A <br /> N CITY <br /> T ENVIRONMENTAL HEAL MAT IIP CODE TYPE of APPLICATION <br /> ] MIJJ�FRVICFS GLawWE. INOTALLAIION. ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> -- <br /> C 1986 1987 1988 1989 <br /> T <br /> Ii <br /> E TANK FEE = 150.00 each TANK <br /> F I Tanks E 550.00 1 <br /> 1 986 1987 1988 1989 <br /> A (multiply (-by fee for <br /> C each year applicable) <br /> 1 <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH L SAF'ETY CODE Sec 25287 for applicability) <br /> T 1 Tanks _� a $56.00 1986 1987 1988 1909 <br /> Y (enter iwunt and year) <br /> I 1 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanks a $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 _ $80.00 each TANK 1 Tanks E $80.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks r $110.00 <br /> E $ <br /> P - <br /> _ <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 = S35.00/hr <br /> _ f <br /> OFFICE USE ONLY TOTAL DUE <br /> MMS <br /> SWEEPS t COMP t LOC CODE 01ST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> n <br /> i. �II�^ I' <br />