Laserfiche WebLink
i uAwU 1 w Lut;AL HLALTH D I R Y G1" <br /> • • GROUND STORAGE TANK PROGRAM - FEE NORKSHEI <br /> __#FA <br /> 1iY/SITE NAME FACILITY CONTACT NAME <br /> T ADDRESS SITE PHONE 1 WITH Aa[A tool <br /> Set-7 v ®` — 94 <br /> Y CITY STA1 IIP CODE It of Tanks <br /> l 0 C K TP YQ at Site lY <br /> A APPLICANTIBILL,ING NAME <br /> P APPLICANT CONTACT NAME <br /> IP 1~ S S L, r�r! D 111 <br /> MAILING ADDRESS APPLICANT PHONE 1 WITH ARCA sour <br /> 64 2 � � � <br /> T CITYf ` t STAT ZIP CODE TYPE of APPLICATION <br /> " f �'^ © t CL0811AE� CMOTALLAT ION, [TC. , `f,/ <br /> J(multipri-rby <br /> LITY FEE _ $100.00 each SITE ADDRESS per YEAR 1 Y� I <br /> TOTAL <br /> 1986 1987 1988 1909 <br /> t <br /> FEE = 150.00 each TANK <br /> nks 1 $50.00 1986 1987 1988 1989 <br /> fee forh year applicable} <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 75281 for applicability) <br /> I <br /> T I Tanks x $56.00 1986 1981 1988 1989 <br /> Y (enter iiount and year) - <br /> L <br /> C PERMANENT CLOSURE {Removal or Closure-in-place} <br /> L �� <br /> D CLOSURE FEE = 190.00 each TANK 1 Tanks x $94,00 <br /> S _ 1 <br /> U - -- <br /> RTEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE : $80.00 each TANK 1 Tanks x $80.00 <br /> 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION 3 ` <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK <br /> E ::��l nks x 1110.00 $ <br /> P ---- _ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (fees are per hour, minimum one hour ESAMPLING <br /> d on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION INSPECTION <br /> (when applicable) (when applicable) licable) <br /> FEE : $30.00/hr FEE _ 135.QOlhra FEE �13S.00/hr <br /> TOTAL DUE -- <br /> OFFICE USE ONLY <br /> FSWIEPSI COMP i LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK IICASH RCVD BY DATE RECEIV€D PERMIT 1 <br /> 0 <br /> �1� RI n � sin <br /> ILII II.�11 nl. 111 nd �i�rum,� <br /> L <br />