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.auAwulry Lua:At. HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> I FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C a,, F / { Ar, <br /> AaG <br /> I <br /> L STREET ADDRESS SITE PHONE 1 wrrw AAc. coot <br /> Y CITY STAT 11P CODE 1 of Tanks <br /> G, So?D at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P r <br /> P <br /> L AS I, a,;,o; - <br /> 1 MAILING AODRES APPLICANT PHONE 1 wrrw ARCA COD[ <br /> A <br /> N CITY ST i iIP CODETik-v PLICA`IONow, ■re. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C1906 1907 1980 1989 <br /> r <br /> F- <br /> I 1 <br /> V <br /> L TANK FEE 450.00 each TANK <br /> f 1 Tanks _ r 150.00 1986 1907 1980 1989 <br /> A (cult,pry 1 by fee for <br /> C each year applicable) O0 <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 45287 for applicability) <br /> I <br /> T 1 Tanks 1 156.00 1986 1907 1908 1909 <br /> Y (enter ii&Nt and year) <br /> t <br /> FCLOSUREFEC <br /> SURE (Removal or Closure-in-place) <br /> $90.00 each TANK 1 TanksSURE (Only allowed one tine for up to two years) <br /> URE FEE = $00.00 each TANK I Tanks z 180.00 1 <br /> LA HECK (Installation or Repair) <br /> ECK FEE • $30.00 each SUBMISSION/RESUBMISSION $ <br /> EIR( <br /> IR FEE = 1110.00 each TANK 1 Tanks x $110.00 <br /> - _AIR/CLOSURE/REMOVAL (Fees are per hour, sini.us one 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/hrlI= 135.00/hr <br /> _ 1 <br /> TOTAL DUE 1 r d ci <br /> OFFICE USE OBLy <br /> 'W 1=181millmll�mmmimflmpmmlll vigil <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCV CH %CASH RCVD BY DATE RICE <br /> PERMIT 1 <br /> ICK�6 <br /> mill Bull <br /> ' ► V <br />