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onAAWu l,r LuL;AL HE`ALT H D I S� CT <br /> ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> 'F FACILITY/SITE NAME _ FACILITY CONTACT NAME <br /> A 'F� AnJ ICS t x xvri. <br /> I <br /> L STREET ADDRESS � X, S[TE PHONE 1 WITH ARBA coac <br /> Tqz <br /> 1 D q Q� <br /> Y CITY A5 CODE <br /> 3 E( t of Tanks 2 <br /> a.�'►/�te CCL, ff� at Site .J <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRES APPLICANT PHONE WITH AREA cont <br /> est Yr ah_ oS0--- a0� Y2- -- 07 `>� <br /> N CITY 4_0 <br /> ^ STAT ZIP CODE TYPE of AP�td#� <br /> LTJ <br /> ! O� IC14 1 h1 — CL 111 YY ALLATIDM. TC. 3 <br /> FACILITY FEE = 1100.00 each SIT\\E ADDRESS per YEAR ALJ [ TOTAL^���"""�������J <br /> A -- <br /> C 1986 1987 1988 1989 <br /> T <br /> I yCso ` $ <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks 1986 1981 1988 1989 <br /> A (aultipIy Fby fee for <br /> C each year applicable) 0 $ Q <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH i SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks_ x $56.00 1986 1987 1988 1989 <br /> Y (enter asount and year) <br /> C PERMANENT CLOSURE (Resoval or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK I Tanks x $90.00 f <br /> S ------ <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks _ _ x $80,00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.40 each SUBMISSIONIRESUBMISSION $ 3 0 <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK 1 Tanks x $110.00 1 <br /> E ------ <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, ainiaua one hour to be paid on plan sQbaittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE = $35.00Ihr $ <br /> TOTAL DUE $ [) e <br /> attic[ USE OILY -� `a-5073 <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 11CASH RCVD BY DATE RECEIVED PERMIT I <br /> I'u, <br /> 11� 'U11 <br /> ryJilIfI� II Iflr�, EMI1111 I^yP 1 !'EP'III¶I <br /> qq......I�111 <br /> 1911 flgnr nll Pes.. tP I�q I'+.Igfl'`I" m.i)'':911 I'rmIIYI� Il lmrlr pl of rsna.tlr Ilnlq <br /> rlil_y.rl•nW��'�i�:�dlnnllLll_?,'I: <br />