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anw JUAWUlry LUGAL HtALTH D "31-RICI' <br /> `JNDERGROUND STORAGE TANK PROGRAM - FEE WORK5r.df <br /> f FACILITY/SITE NAME <br /> A FACILITY CONTACT NAME <br /> C %a <br /> I - <br /> L STREET ADDRESS SITE PHONE 1 WITH A•[. aoo[ <br /> -, <br /> T <br /> Y CITY STAT 71P CODE 1 0l Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 <br /> C — ^ WITH A[[[ COD[ <br /> N CITY STAT ZIP COBE TYPE of APPLICATION <br /> T �, CLD[w[E. IY[1�LLw flow, [TC. <br /> AFACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> — <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 f <br /> V <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks _ 1150.00 1986 1987 1988 I9B9 <br /> A (Uulhpfy'I by fee .0r <br /> C each year applicable) <br /> I 1 <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks a '56.00 1986 1987 1988 1909 <br /> Y (enter iiouit and year) <br /> f <br /> C PERMANENT CLOSURE (Removal 6r Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks a 190.00 f <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up top ars) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK tvzc Ii <br /> Ei T Tanks [ $80.00 <br /> f <br /> P PLAN CHECK (Installation or Repair) 3 <br /> L 1 1a, <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESU/gyp Nrq/ <br /> S <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK t Tanks x $110.00 <br /> E 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 FEE = 135.00/hr FEE = 135.00/hr <br /> f <br /> DFritE USE ONLY <br /> ' r <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br /> ..I' , _3 iii <br /> I' M Illllltlm ! II01 IX II i <br /> 9MVr�EVJ,IJutmlmom�illud I),voisli mu 1Hiup�°, <br />