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OM14 .IUAUUIN LOCAL HEALTH DISTRICT UN OU - FEE WORKSHEET .... _.._. . ND STORAGE TANK PROGRAM FACILITY/SITE NAMEO — FACILITY CNTACT NAME --- I STREET ADORE5S I SITE PHONE # WITH AREA CODE _ T ------..._...- -- — ---- ------- - - Y CITY - — STATE ZIP CODE # of Tanks at Site A APPLICANT/BILLING NAME P APPLICANT CONTACT NAME F L- -- -- - --.....__...--- - -..._.. _._..- - ------ -- 1 MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A_.._. — --------------- N CITY —...-- T STATE ZIP CODE TYPE of APPLICATION CLOSURE. INeTALLAT ION. ETC. FACILITY FEE - $100.00 each SITE ADDRESS per YEAR TOTAL T -] ......................... 1987 — 1988 --1989 - I E TANK FEE = 450.00 each TANK _....._....._........ _................_....__._...._........_ .— F f 1 Tanks _ x 450.00 1986 1987 1988 1989 A (mu l t i p f y by fee for _.....-----......-- -- — ----- ...— -- — ----------- — C each year applicable) 1JIII $ L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH A SAFETY CODE Sec 25287 for applicability) —— — —_— - i # Tanks x E56.00 1986 1987 1988 1989 Y (enter ieount and year) ------•-- -.--_ .............................._--— -- --- — --_ —...__-- -- — --- C PERMANENT CLOSURE (Removal or Closure-in-place) # D CLOSURE FEE _ $90.00 each TANK — z 490.00 --- S --- --....-- ----- -- — — R TEMPORARY CLOSURE (Only allowed one time for up to two years) — — — E - — — -- - — -..— —— ---— -- — TEMPORARY CLOSURE FEE _ $80.00 each TANK # Tanks x $80.00 E _ IP PLAN CHECK (Installation or Repair) L..__._.._..._..._-- -- ._.. - ---— — ----- - ----------- — —- — _ -- - --- A N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION f REPAIR R TANK REPAIR FEE = 4110.00 each TANK E___.____._._._...__...._....._..__..____..._._.----_._...-----_-..-- .---.. $ Tanks z $110.00 f A PIPING REPAIR,/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) — R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION (when applicable) (when applicable) (when applicable) FEE _ $30:001hr1 _^ _ FEE_$35iODA r[ ^-- — FEE '$35_00/hri TOTAL DUE f OFFICE USE ONLY ` -- I�I��I�QI I10199II99m,inllq.....1, �I��II�I�@.II��I�II�II�II�� '��I��lanl��!I�Ill�lllllllnln�l�l��l@I�Illl�l��llll��lll�li�l.N�l�l�in��lll�!�II�I�II�I�I QI�I�I�I�I�Alll�ll�l, SWEEPS I COMF # LOC -00E 019T CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT 1 _.. _.._. .. . .............---- -- —......... — — .l�lmlll�llll��lla� ��I�!mll��!Im .mml�mlll�lllll��llq .�ml�lmm�mm�mmmml� mll�lmlml�u�u�!I �� I�mmmm�m�ml��llll�l .��I��I�I�nllm�l�ml��.l