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k� \\ Qni% -WAwUlav LUA.I HEALTH DIN.-/RICT <br /> I.dERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> r FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C hdlPG! uS� <br /> l <br /> L STREET ADDRESS SITE PHONE t <br /> YITY Mc. comm <br /> T 3? 3 D u r�C%s-e C� o y3/-566 / <br /> Y CITY STAT ZIP CODE 1 of Tanks <br /> S"/l ', at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P _ <br /> �Gi i.�¢e-r G.� Y <br /> L <br /> I MAILING ADDRESS APPLICAN WITM A•ma coos <br /> C G- �. 7 9 <br /> r, <br /> M CITY SJ(TJ 11P CODE LO APPLICATION <br /> A FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1981 1988 1989 <br /> r <br /> 1 <br /> v 1 <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks _ ► 150.00 1986 1981 1988 1989 <br /> A Uult,ply 1 by lee lo► <br /> C each year applicable) <br /> I Ef <br /> L STATE SURCHARGE = <br /> 1 $56.11 0 11 0 each TANK (see CA HEALTH t SAFETY CODE Set 25281 for applicability) <br /> T 1 Tanks s ''56.00 1986 1981 1988 1909 <br /> Y tenter iii and year) <br /> 1 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = 190.00 each TANK t Tanks _ _ Y f90.00 { <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 t Tanks __ s (80.00 <br /> P PLAN CHECK (Installation or Repair) <br /> A D �rvµ 0 Ye 1e <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION - - - <br /> f <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK <br /> E 1 TarI v (110.00 { <br /> P <br /> A PIPING REPAIR/CLOSURE/RENOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) when applicable) (when applicable) <br /> FEE = 170.00/hr FEE _ '']5.00/hr FEE _ $95.00/hr <br /> $ <br /> TOTAL DUE { �� <br /> OFFICE USE ONLY <br /> SWEEPS t COMP 1 LOC CODC DIST CODE ANOUNT DUE AMOUNT KCVO <HCCK IICASH RCVp DY PATE RCCEIVCO PCRMIT <br /> Ifn::7f Oilp„1) 111411 li . _ SZ' gni s p y ;y u m _ 9 <br /> �11-07��� �I�o.aq������p��qq��e����n��iin����������ppqq pp��yy��pp������������ '�1PJlil.1.l/Id pI11991111aNV4011�fVNIl01l1�IIIpIN�,G11,NIPIII• <br /> 'MIW�WY�YItlItlYY ���y�JIIYWY � � ' opi N 0 Pi i i i <br />