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QmN JUAWUIN LOCAL HEALTH DISTRICT UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET A FACILITY/SITE NAME FACILITY CONTACT NAME C 5E13D-t> �. I STREET ADDRESS SITE PHONE t WITH AREA CODE T 6ZO S. flW�72�CF�� Z6� S48-Zlsz _ Y CITY STAT ZIP CODE f of Tanks jTZXK �' CFY aSZUC_0 at Site AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME P L I MAILING ADDRESS APPLICANT PHONE t WITH AREA CODE C A — N CITY STAT ZIP CODE TYPE of APPLICATION I CLOSURE, INSTALLATIDN, ETC. FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL A -- -- — — C 1986 1987 1988 1989 T 1 V f _ E TANK FEE _ $50.00 each TANK F t Tanks _ for x (50.00P"i4 1981 1988 1989 - A (multiply_1 by fee -- --- -___ -— C each year applicable) $ a I L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) I —_ _ T t Tanks - x $56.00 1986 1987 1988 1989 Y (enter ziout and year) _ f �- C PERMANENT CLOSURE (Removal or Closure-in-place) I Z L — - — 6 CLOSURE FEE _ $90,00 each TANK t Tanks_ a2 x $90.00 — $ 00 U— R TEMPORARY CLOSURE (Only allowed one time for up to two years) E TEMPORARY CLOSURE FEE = $80.00 each TANK --� t Tanks x $80.00 f p P PLAN CHECK (Installation or Repair) L— A A N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ REPAIR — R TANK REPAIR FEE = $110.00 each TANK t Tanks x $110.00 f E— P - --- A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) I -- R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION (when applicable) When applicable) (when applicable) FEE = $30.00/hr FEE = $35.00/hr — FEE = $35_00/hr $ fa TOTAL DUE $ OFFICE USE ONLY SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO CHECK t/CASH RCVD BY DATE RECEIVED PERMIT t u l u N