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ans% JUAwU1w LUL;AL HEALTH DISI-RICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C <br /> 1 <br /> L STREET ADDRESS <br /> I g � � �� a c,S SITE PHONE 1 WITH eYc• cone <br /> T S. cS S bo <br /> Y CITY STAT IIP CODE 1 of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> L �G S S CR_ll1} r <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 WITH •RKA Cone <br /> pr, c r .d e <br /> N CITY STAT IIP COD TYPE of APPLICATION <br /> III 0, S C(k 95 6 1 CLanuec. IMYrALLwrInY. ere. <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> I <br /> V f <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks r 150.00 1986 1987 1988 1989 <br /> A (multipry-1-by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25281 for applicability) <br /> I <br /> T 1 Tanks : 156.00 1986 1981 1988 1989 <br /> Y (enter iiount and year) <br /> $ <br /> FCLOSURE <br /> SURE (Removal or Closure-in-place) <br /> t90.00 each TANK1 Tanks ( s (90SURE (Only allowed one time for up to two years) <br /> SURE FEE _ $80.00 each TANK 1 Tanks $80.00 f <br /> P PLAN CHECK (installation or Repair) El <br /> L <br /> A 8 1989 <br /> N PLAN CHECK FEE _ (30.00 each SUBMISSION/RESUBMISSION Sgry JO f <br /> REPAIR til HEALTH Vf�ES <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks z $110.00 $ <br /> E <br /> A PIPING REPAIR/CLDSURE/REMOVAL (Fees are per hour, minimum one hour to he paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr FEE I: $35.00/hr FEE I: $35.00/hr $ <br /> OFFICE USE ONLY TOTAL DUE <br /> i <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHEC 1/CASH KCVO BY DATE RECEIVED PERMIT 1 <br /> tltl '1 �/0.cTL) V S /U ft <br />