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Awulw LuL:AL HtALTH DIQ 11L'T IF STORAGE TANK PROGRAM - FEE WORKSHEEE F FACILITY/SITE NAME — FACILITY CONTACT NAME I _ __ C 1 _ L STREET ADDRESS S[TE PHONE t WITH AREA CODE _ - T .20 � U� Fla �.2Jr-t/ Y CI1YC l� �9{� STATE ZIP CODE t of Tan ks at Site A APPLICANT/BILLING NAME APPLICANT CONTACT NAME - P L I MAILING ADDRESS APPLICANT PHONE t C WITH AREA CODE A N CITY S:TA T ZIP CODE TYPE of APPLICATION T CLOSURE. INSTALLATION, ETC. FACILITY FEE = $100.00 each SITE ADDRESS per YEAR — — -- TOTAL T 1986 1987 1988 1989 I -- V 4 OU E TANK FEE _ $50.00 each TANK - F t Tanks x $50.00 1986 1987 1988 1989 A (multipTy-I1by fee for C each year applicable) I F-' r' - G— 5� __ _- ZC>c> - L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH A SAFETY CODE Sec 25287 for applicability) T t Tanks x $56.00 1986 1981 1988 1989 _ Y (enter aaount and year) _ ------ ----------- FTEA OSURE (Removal or Closure in place) = $90.00 each TANK -- -- t Tanks x $90.00 OSURE (Only allowed one time for up to two years) —— --� _ OSURE FEE _ $80.00 each TANK t Tanks x 480.00 $ --�_-- P PLAN CHECK (Installation or Repair) — -- --- -- L A ` _ --- --- - — N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ REPAIR R TANK REPAIR FEE = $110.00 E_. each TANK rI Tanks...... x $110.00 $ P -- ,.-_._._..._.... - -- A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to he paid on plan submittal) R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION - — (when applicable) (when applicable) (when applicable) IEE = 430.00/hr FEE _ $35.00/hr FEE _ $35.00/hr — — - -_--_L- -- - --- --- --- - $-- - TOTAL DUE f OFFICE USE ONLY JB SWEEPS t COMP t LOC CODEGIST CODE AMOUNT DUE AMOUNVD CHECK t/CASH RCE RECEIVED PERMIT {