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, Ully LUCAL HEALTH DISI' 'CT <br /> UNDeRaROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> [MAILING <br /> ITY/SITE NAME fTYPE <br /> Y CONTACT NAME <br /> c <br /> UcADDRESS _i5E14vc'VLON t- NE I WITH AREA CODE of Tanks <br /> SiteANT/BILLING NAME <br /> T CONTACT NAME ADDRESS <br /> T PHONE t WITH AREA CODE STAT PE of APPLICATIONOSURE. INSTALLATION. ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 <br /> V ✓ $ 16Z� <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanksf _ x $50.00 1986 1987 1988 1989 <br /> A (multiply I by fee for <br /> C each year applicable) <br /> I ✓ $ SU <br /> L STATE SURCHARGE = 456.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks 1 $56.00 1986 1987 1988 1989 <br /> Y (enter 565ht and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK t Tanks x (90.00 <br /> S $ <br /> U <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 $80.00 <br /> S <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> 4 <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK $ Tanks x $110.00 <br /> E $ <br /> P - <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (When applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr <br /> f <br /> OFFICE VSE ONLY TOTAL DUE <br /> inXIR;PYIXI!� XX� 4 p II I ��t� .tl (il a 1111!911 �� til!I 1114 M X�m! I Oi!I II Ilu.ltl^ I n Im I III 'II nll Innlll I III PI I i I I'I X!X I II <br /> I b 1 II II ll,l m..uum';,I <br /> SNEEPS t COMP 1 LOC Cff ODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH KCVO BY DATE RECEIVED PERMIT t <br /> TTd7�f111�`.y.T. lulblllX <br /> Y ^ Yi'.��.I � X�i alai lwV II '' Oin 1 . <br /> ' RLYIJ 'I;I O 1 nil Ilxl . XI 141LF.n. I I m I L II,'IX!I ;Illl l��P;IP911n plllll p�l PII�Mmlllllf;l' Y PI ui IIIN xl.9tll'. Ipg n I •I „ RlnWlln i n m <br />