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5Hn JUAUU11V LUCAL FIEALTH D TRICT <br /> ONDERGROUND STORAGE TANK PROGRAM FEE WORKS <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> -A <br /> L STREET ADDRESS \3 SITE PHONE 1 WITH AREA COON <br /> I i <br /> Y CITY STATE ZIP CODE 1.t of Tanks <br /> _ —� at Site <br /> A APPLICANT/DILLING NAME _ APPLICANT CONTACT NAME-- — <br /> P <br /> P <br /> L—_ _.— —.----- --- - — <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> O <br /> A -----_— r ------ — <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T — — -- ---- --- CLDeURE, INOTALLATION, ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR — TOTAL <br /> A...----- - - E <br /> --- - _ _-- <br /> T / ' Y C G CPE 986 1987 8 1989Poi 86 8 7 8 <br /> E TANK FEE _ $50.00 each TANK <br /> 1B 1989 <br /> F t Tanks _ x $50.00 = 8 -s9B0 <br /> A (multipfy 1 by lee !or O.GD0 -0 C_3--� / <br /> C each year applicable) 60 00 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks I x $56.00 1986 1987 1988 1989 <br /> Y (enter mount and year) ----- - -— -- <br /> C PERMANENT CLOSURE (Rel l or Closure-in-place) — <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK t Tanks--__ x 190.00-��� p 0 <br /> U -- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E-- ------- - <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks —x 180.00 f <br /> L PLAN CHECK (Installation or Repair) <br /> II PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION $ <br /> -- REPAIR <br /> P, TANK REPAIR FEE = 1110.00 each TANKI Tanks - x 1110.00 <br /> E 1 <br /> .._....--_.—_---------.__..._.. -- ....__...__..._._....- <br /> P -------- ------ -- --._.._-� -- -- --_--- <br /> A PIPING REPAIR./CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLIV A15REpYla 14 <br /> (when applicable) when applicable) (when Rpta*i V_ Q — <br /> g -- <br /> - FEE = f30.001hrI -- FEE = 135 nh ' - -^ FEE _ ta5.•QO/hr� S — <br /> OFFICE USE 0N(Y F 989ENVIRONMENTAL <br /> —f_O M E � 16- Di✓ <br /> ENVIpROp,N�ME/NTAL HEALTH' <br /> IIC�911CCCCCVNICCCCCIIIIICCCIICIICCIICCICIICIIICIIC�II@C!I�VIImuCCCupIlClll!I!CCCmJCIICIICC pigiCB VAI mon IUIIuuCIICIUIIII IIIIIIrIII�Q�ImI II I Id1 1 kDATE <br /> NUDICNDIIICIIICIClluuluSWEEPS I COMP t LOC CODE DIST CODE AMOBkR18V SGBI WVD CHECY. I/CASH RCVD BY RECEIVED PERMIT t <br /> F "l �qC �� S -J1 --- <br /> 41171�' P iPC I C!LCIICPIICIIINII!ICOn CIIICCIICIICi!IV" "' ICIICICIC!C�II!Cglll!!PClla CCCCICIWCIICICICICICIIIIIICiICC IICC!IIIIIPCCCCCIVI�IC!IICCCIIIUIII l!ICICIICIIIIIIICIIICCCIIIICCCCV6iClli!iIICIII�VCICICCCCOV1�11111WIIIC <br /> Il11" <br /> G � f e& ,A- <br />