Laserfiche WebLink
-o"j4 v k olkwu 1 iv LURAL Hr.ALTH DIS", <br /> Cl' <br /> UigROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> r FACILITY/SITE NAME FACILITY CONTACT NAME <br /> ., <br /> C s;�P f f 7 v t !V1 ►'1'l <br /> L STREET ADDRESS SITE PHONE 1 WITH ARCA Cao[ <br /> 1 3 60 7La Yea Iu 14 21 — <br /> T24 1 <br /> Y CITY STATEI 71P CODEI of Tanks <br /> l C C 'K4 N at Site (� <br /> A APPLICANTIBILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P �Y� f � LD C k' S <br /> I MAILING ADDRESS APPLICANT PHONE 1 �iTH AR[A caor <br /> CP, vx cc 1 - � l - 04 <br /> N CITY STATE IIP CODE TYPE of APPLICATION _ <br /> T r � lrr� <br /> L-1—O Tx y CLotlUR[� IMiTALIATIQH� [TC. IP} L _r^J p P L <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR 1 f�TOTAL1 <br /> A <br /> C 1986 1997 1988 1989 <br /> T <br /> 1 s <br /> v <br /> E TANK FEE _ $50.00 each TANK <br /> r I Tanks x 350.00 1986 1987 1988 1989 <br /> A (multiply l'by fee for <br /> C each year applicable) $ <br /> L STATE SURCHARGE = f5G.00 each TANK (see CA HEALTH t SAFETY CODE Sec 25207 for applicability) <br /> I <br /> T f Tanks x 155.00 1986 1987 1988 1909 <br /> Y (enter i±ount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK I Tanks x $90.00 $ <br /> S ---- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to tyo years) <br /> El T <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK I Tanks_ x $00.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSIONIRESUBMISSION <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK 11 Tanks _ x $110.00 $ <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, ainimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE = $35.00/hr p FEE <br /> TOTAL DUE s <br /> OFFICE USf OILY <br /> tt <br /> I i i� Ii fi R I <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT I <br /> TRIM <br /> ll l I Vrnm1 rill <br />