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bAN .i OAQU 1 )til LOCAL HEALTH DISTRICT <br /> ERGROUNQ STORAGE TANK PROGRAM - FEE 1IORKSH <br /> _ <br /> ._.--------------------- <br /> �F1`FACILITY/SITE NAME . FACILITY CONTACT NAME <br /> L STREET ADDRESS SITE PHONE # WITH AREA CODE <br /> ...-............... Q 8 i <br /> YCITY TE ZIP CODE 1 of Tanks <br /> �T,2at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P I / <br /> ..._..��lis. _...._............ <br /> I MAILING ADDRESS APP IGANT PHONE # "I T" AREA COM <br /> r -" <br /> -- -" o `A('r _ ---- _.-......... <br /> ..-_—_ <br /> N CITY / STATE ZIP CODE !LURE PPLICATION <br /> T S INEITALLATIOH. ETC. <br /> FE[LITY FEE = $100.410 each SITE ADDRESS per YEAR _.---..---------.----------,..._._._.--__ -- TOTAL — <br /> A ---- <br /> C 1986 1987 1988 1989 <br /> T <br /> 4 <br /> € TANK FEE = $50.00 each TANK <br /> __._._.... - ...._...__.............._....-- __ _ ._._ .. __ __....._._...__.,._.-...-__.-.-_ .._..._._._............. <br /> ........ <br /> ..._.. <br /> F # Tanks _ x $50.00 158b 1987 1988 - 1989_ - -T <br /> A (multipfy f-by fee for <br /> C each year applicable) $ <br /> L STATE SURCHARGE = $56.00 each TANK-(see CA HEALTH SAFETY CODE Sec 25287 for applicability) <br /> T # Tanks----- x 556.00 — 1986 1987 _ 1988 1989 <br /> Y (enter t and year) .—._--- <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> O CLOSURE FEE = 590.00 each TANK # Tanks7 x $90.00 5 <br /> R TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION $ <br /> -..._....._._-._.............. <br /> I REPAIR <br /> .__..__..:..____........_.. <br /> R TANK REPAIR FEE = $110.00 each TANK # Tanks x $110.00 5 <br /> E ____........ <br /> . <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> __—_ —_ _ - _ _. <br /> FEE = $35.00hr <br /> FEE -(30 00/hr FEE - $35 001h <br /> f $ <br /> TOTAL DUE — x <br /> OFFICE USE ONLY <br /> ---— / u .. <br /> lf'CII1!Is!GRtI!'�!1�1�Ii�lali I f�i iIV� f EI H�' ;f P`!i G ISI!H11I!"Ilu�i➢ illi ! g li[<I({� li { II I€l�ii�ll�l�l II!IIII�BIf� IIN I��Illlll�n���ti!111111�111 I�I�IiI�E IIU@ill!�I!Ill�ll!illllly!�Illl�li?f€I�ICR <br /> I� SWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD C1{�K /CASH RCVD BY DATE RECEIVED PERMIT k <br />