Laserfiche WebLink
onllf .,u Ulw LUCAL HEALTH DIST OCT <br /> LIND UND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F ACILIT /SITE NAME FACILITY CONTACT NAME <br /> C d 0-� PAYMENT <br /> 1 RECEIVED <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA CODE <br /> 1`4 AY <br /> s ��Is3 <br /> Y CITY �DC�r' STAT IIP CODE t of Tanks <br /> at Site ENVIRONMENTAL HEALT <br /> F APPLICANT/BILLING NAME APPLICANT CONTACT NAME ICES <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH ARCA CODE <br /> C <br /> A <br /> N CITY STAT ZIP CODE TYPE of APPLICATION <br /> T CLORwRE. INBTALLATION, ETC. <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 1986 1987 1988 1989 <br /> I 610 C,U /00 _ /00 $ <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks �_ _ x 1150.00 1986 1987 1988 f 1989 <br /> A (multiply I by lee for <br /> each year applicable) 5U <br /> L STATE SURCHARGE = $56.00 each TANK (see CA EALTH L SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> T 1 Tanks z $56.00 1986 1987 1988 E[Efgag <br /> Y (enter amount and year) <br /> f <br /> ECIDSURE <br /> OSURE (ReETANK <br /> e-in-place) <br /> _ $90.00 1 Tanks z $90.00OSURE (Onitime for up to two years) <br /> OSURE FEE TANK 1 Tanks z $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR — <br /> R TANK REPAIR FEE = 1110.00 each TANK 1 Tanks x 5110.00 $ <br /> E <br /> P - <br /> A PIPING REPAIR/CLOSURE/REMOVAL (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 = S30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr <br /> _ f <br /> TOTAL DUE S UU <br /> OFFICE USE ONLY <br /> ...... 1plr --- <br /> COMP I <br /> 000MPILOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> �� I h ,1(11 I ',! U .,,,Tu till) 1,lll,lll,ml;lrlI IIm' ., • r.a, <br />