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:"J% 4UArlu1r4 Lut�AL HLALTH DIFI-RICT <br />�ERGROUND STORAGE TANK PROGRAM - FEE NORKSHEL� <br />FACILITY/SITE NAME FACILITY CONTACT NAME <br />STREET ADDRESS SITE PHONE 1 WITH ARCA COOK <br />CITY STAT IIP CODE 1 of Tanks <br />at Site <br />APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br />NAILING ADDRESSAPPLICANT PHONE 1 "IT" AREA Cont <br />CITY STAT ZIP CODE TYPE of APPLICATION <br />CLO•UA C. INSTALLATION, RTC. <br />FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br />TOTAL <br />1986 1987 1988 1989 <br />1 <br />V <br />1 T <br />/& J 1 <br />0.00 <br />TEMPORARY CLOSURE (Only allowed one time fob 01t4 s) <br />1 <br />E TANK FEE _ $50.00 each TANK <br />1 Tanks <br />a $80.00 <br />F 1 Tanks 3 1 $50.00 <br />A (multiply -1 -by lee for <br />1986 <br />1987 <br />1988 <br />1989 <br />, D <br />C each year appluablel <br />I <br />%So <br />% <br />/5 � <br />S o $ <br />L STATE SURCHARGE = $56.00 each <br />1 <br />TANK (see CA <br />HEALTH i SAFETY <br />CODE Sec 25287 <br />for applicability) <br />f 1 Tanks t 156.00 <br />(enter amount and year) <br />1986 <br />1987 <br />1988 <br />1989 <br />/CLOSURE/REMOVAL (Fees are per hour, minimum one <br />!=C <br />hour to be <br />PERMANENT CLOSURE (Removal or Closure -in-place) <br />CLOSURE FEE _ $90.00 each TANK <br />1 T <br />/& J 1 <br />0.00 <br />TEMPORARY CLOSURE (Only allowed one time fob 01t4 s) <br />TEMPORARY CLOSURE FEE _ $80.00 each TANK VF <br />1 Tanks <br />a $80.00 <br />f <br />PLAN CHECK (Installation or RepairANV/ 19q'� <br />_ <br />PLAN CHECK FEE _ $30.00 each SUBMISSION/FRr N� <br />f <br />REPAIR <br />FEE = $110.00 each TANK <br />1 Tanks <br />z $110.00 1 <br />/CLOSURE/REMOVAL (Fees are per hour, minimum one <br />!=C <br />hour to be <br />paid on plan submittal) <br />RELEASE EVALUATION CONSTRUCTION INSPECTION <br />ble) <br />SAMPLING INSPECTION <br />(when applicable) <br />(when <br />applicable) <br />hr FEE = 135.00/hr <br />FEE = <br />135.00/hr <br />t <br />OFFICE USE ONLY TOTAL DUE <br />M11120 .—INTI <br />SWEEPS 1 COMP t LOC CODE DIST COpE AMOUNT DUE AHOUfTiRZWD CHECK 1/CASH RCVD BY DATE=RECEIVED PERMIT 1 <br />Dllfi"N"IIIOIINtlfMltlNtlmmmrm�nmm�r nlMlmnMNNW n ` `*^� '�- <br />