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omN jL14wu1N LOCAL HEALTH DIST^'TCT <br /> Uft,.4iOUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> 1 <br /> 13 r7iP�' Caet�u �iu Ia�cQ <br /> L STREET ADDRESS ITE PHONE 1 WITH AREA CODE <br /> I z !v i3A'-' Zt 011 <br /> T <br /> Y CITY STAT ZIP CODE ji of Tanks—�-- <br /> �, i� ` �S at Site <br /> A APPLICANT/BILLIN NAME APPLICANT CONTACT NAME <br /> 1 MAILS, ADDRESS APPIJ NT PHONE 1 WITH AREA CODE <br /> A %G _ fd <br /> T CITY ��� STAT ZIP CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A — ---— — — <br /> C 1986 1987 1988 1989 <br /> T — <br /> I /��� C0 (00 UU $ C'4m <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks x $50.00 1986 1987 1988 1989 <br /> A (multipfy_I by fee for — —— <br /> C each year applicable) 2 C)o 2 c 2_p h 2 00 f C C) <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH b SAFETY CODE Sec 25297 for applicability) <br /> I <br /> T 1 Tanks z $56.00 1986 1987 1988 1989 <br /> Y (enter 5io5nt and year) , — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks x $90.00 f <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 f <br /> P PLAN CHECK (Installation or Repair) — <br /> L --- <br /> A <br /> N PLAN CHECK FEE = $30.00 each SU!?_S]ON/RESUBMISSION <br /> f <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.0each TANK j# TTanksx $110.00 f <br /> E <br /> P <br /> A PIPING REPAIR/CLOSU /REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RE ASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applica e) (when applicable) (when applicable) <br /> FEE = $30. !hr FEE = $3 . 0/hr FEE _ $35.00/hr $ <br /> -------- TOTAL DUE <br /> 0FF1 OSE I'll <br /> WEEPS 1 COMP az1 =CODIST =I/CASHAMOUNT DUE AMOUNT RCVODATE RECEIVED PERMIT 1 <br />