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.� Iwo <br /> amA JUAWUlry LUUAL HEALTH DISINICI <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILIT CONTACT NAME <br /> A <br /> L � r <br /> t <br /> L STREET ADDRESS SITE PHONE 1 (with Area C e) <br /> I <br /> T <br /> Y CITY STATE ZIP CODE t of TANK'S <br /> A ,Z O Sat Site w <br /> A APPLICANT/BILLING NAME APPLICA T CONTACT NAME <br /> F <br /> f 6 <br /> L <br /> I MAILING ADD ESS APPLICANT PHONE 1 (with Area Code <br /> A oX p <br /> N CITY (- J STATE IIP CODE T PLICATION <br /> T l r S ��o s1tlosurp Installation, etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1981 1988 1989 <br /> F <br /> I f <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks _ _ x f50.00 1986 1981 1988 1989 <br /> A ieulh pIy I by (ee for <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25281 for applicability) <br /> I <br /> T t Tankss (56.00 1986 1981 1988 1989 <br /> Y (enter Mount and year) <br /> f <br /> C PERMANENT CLOSURE (Resowal or Closure-in-place) <br /> L <br /> 0 <br /> S CLOSURE FEE _ $90.00 each TANK It Tanks--j__ x $90.00 f <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tiee for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK t Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P 1 Tanks x $110.00 t <br /> A --- <br /> 1 PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, einisue one hour to be paid on plan subeittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 530.00/hr F FEE _ $35.00/hr FEE _ $35.00/hr f <br /> TOTAL DUE f 0 <br /> OFFICE USE OILY <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> I <br />