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omj% . UAwUIH LUCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> I <br /> kF <br /> /SITE NAME A��o FACILITY CONTACT NAME <br /> P i <br /> DDRESS SITE PHONE�I JTN AREA C00E i(oMQ <br /> Z <br /> of Tanks <br /> t Site <br /> Y APPLICANT/BILLING NAMENT CONTACT NAME <br /> L1 MAILING ADDRESS NT PHONE t wl*N ARCA EonE <br /> CA f d �e ) 9� -8.2,5N CITY YPE of APPLICATION <br /> ���� LOeUA E. UfTALLATION. ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1 1988 1989 <br /> T <br /> I <br /> V $ /00. 00 <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks _ x $50.00 1986 1987 1988 1989 <br /> A (Aultipry ( by fee for <br /> C each year appLcahlel f /SQ D O <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH i SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter imount and year) <br /> C PERMANENtCLOSURE Removal or Closure-in-place)L0 CLOSURE 00 each TANK1 Tanks z (90.00SU - <br /> R TEMPORAROnly allowed one time for up to two years)ETEMPORAREE = $80.00 each TANK 1 Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> LFA <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ O 00 <br /> WKR <br /> IR FEE = 1110.00 each TANK 1 Tanks x (110.00 $ <br /> - <br /> AIR/CLOSURE/REMOVAL (Fees are per hour, minimumone hour to be paid on plan submittal) <br /> ED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> icable) (when applicable) (when applicable) <br /> 00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $ p p <br /> OFFICE USE ONLY <br /> r,.. <br /> A 9 l� ml IiCOMP $ LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> (J r <br /> Fu y� cv /a'� °ITP I'u.RlNln°�IL'i16��GIII�Ct'lt Y�1,n9�u m�III � � 1 x$•1;1911 (p!l I N a Lncl nl•gl, <br />