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5nN .1UAWUlm LUGAL HtALTH D16lKiGI <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILIT CONTACT NAME <br /> A <br /> L — r <br /> L STREET ADDRESS SITE PHONE D (with Area C e) <br /> [ <br /> r 0 C7 <br /> Y CITYSTATE LIP CODE 1 of TANK'S <br /> A r 20 <br /> S„ at Site w <br /> A APPLICANT/BILLING NAME ,L/ APPLICA T CONTACT NAME <br /> P / <br /> P <br /> L <br /> I MAILING ADD ESS APPLICANT PHONE 1 (with Area Code) <br /> A ��- <br /> N CITY r 1 STATE LIP CODE - T PLICATION <br /> L J r S 1p S' losur Installation, etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> I f <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks _ _ x (50.00 1986 1987 1988 1989 <br /> A (multiply 1 t fee for <br /> C each year applicable) 1 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks x 156.00 1986 1987 1988 1989 <br /> Y (enter iiount and year <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK <br /> S 1 Tanks____ x $90.00 f <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 Tanksx $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L RECIElVED <br /> A <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION APR 1 '0989 <br /> R REPAIR ENVIRONMEPITAL HEALTH <br /> E TANK REPAIR FEE = 1110.00 each TANK 1 Tanks_____ x 1110.00 <br /> PERM!if!TomP <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, ■inimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 130.00/hr fEE _ $35.00/hr FEE _ $35.00/hr f <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE I AMOUNT DUE AMOUNT RCVD CHECK 11CASH RCUn BY DATE RECEIVED PERMIT 1 <br /> r$ac� hl�li X19 - pp — qD — 00 - <br />