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onn Awul,4 LOCAL HEALTH DI icy <br /> GROUND STORAGE TANK PROGRAM - FEE VORKSHEEI� <br /> r <br /> FACILITY CONTACT NAME <br /> F FACILITY/SITE NAME <br /> �� C�aY,� <br /> I <br /> L STREET ADDRESS C SITE PHONE t WITH AREA CODE <br /> T <br /> Y CITY STAT ZIP CODE 1 of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P �� SE tz✓ r <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE t WITH AREA tout <br /> C <br /> N CITY STAT ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 t988 H989 <br /> V <br /> E TANK FEE = $50.00 each TANK _ <br /> F 1 Tanks x $50.00 1986 1587 1988 1989 <br /> A (EultiplylI_by fee for <br /> C each year applicable) <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter 555t and year) - <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> O CLOSURE FEE _ $90.00 each TANK 1 Tanks __ z (90.00 f 9(J <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $30.00 each TANK 11 Tanks 1 $80.00 f <br /> P PLAN CHECK (Installation or Repair) PAYMENT <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION APR $ <br /> REPAIR b1V'RQW'AAEtslT.A.1-' 14P FH <br /> R TANK REPAIR FEE _ $110.00 each TANK t Tanks x # @PAOI SERVICES I <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 /> IEE = $30.00/hr FEE _ $35.00/hr FEE = $35.00/hr f <br /> TOTAL DUE s 2- <br /> OFFICE USE ONLY <br /> 7PERM1,Tl'# <br /> SWEEPS t COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK /CASH RCVD BY DATE RECEIVED a39 v.s J'IIII91111 <br />