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r "O" 4UAWUI14 LUc;AL HEALTH DISTRICT <br /> F F?CILITY/SIiE NAME UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> A FACILITY CONTACT NAME <br /> C <br /> L STREET ADDRESS <br /> SITE PHONE 1 MITM ARCA Coo, <br /> Y CITY �� <br /> STAT TIP CODE 1 of Tanks <br /> A APPLICANT/BILLING NAME at Site <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> 1 MAILING ADDRESS <br /> C APPLICANT PHONE 1 MITM AA94 Coo, <br /> A <br /> N CITY <br /> T STAT1 ZIP CODE TYPE of APPLICATION <br /> CL=!uA[. INATALLATIGM. [TC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> A r TOTAL <br /> C 1986 1987 1988 1989 <br /> 1 ' <br /> VSf <br /> E TANK FEE $50.00 each TANK <br /> 7. <br /> F 1 Tanks _ _ x sS0.00 INV , <br /> A (A ltiply 1 Dy lee for 1986 1987 1988 1989 114 N <br /> C each year appli able) <br /> I <br /> L STATE SURCHARGE = 6 <br /> 1 .O each TANK (see CA HEALTH L SAFETY CODE Sec 25281 for applicability) <br /> T 1 Tanks % x $56.00 1986 1987 1988 <br /> Y (enter iiount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks x 190.00 <br /> S 1 <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks x 180.00 <br /> f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION <br /> f <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK <br /> E 1 Tanks x (110.00 f <br /> P _ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr LEE _ $35.00/hr FEE _ $35.00/hr <br /> 1 .3 OCo - fJc7 <br /> TOTAL DUE 1 �" <br /> DfFFCf USE ONLY <br /> SN COMP D LOC CODE DIST CODE AMOUNT DUE AMOUNT <br /> �1/CASH RCVD BY GATE RECEIVED PERMIT 1 <br /> � n <br />