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0-4Auull4 Lut;AL HEALTH DI ICI" <br /> ORGROUND STORAGE TANK PROGRAM - FEE NORKSHE <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> 1 rc <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA C069 <br /> Y CITY v STAT IIP CODE 1 of Tanks <br /> oc- dn1 C _52_z>y at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P ^�f 1J <br /> P /'�I ke <br /> L / <br /> I NAILING ADDRESS ff APPLICANT PHONE 1 Nit" AREA CODE <br /> C Z cx$Y/^ 7dn) <br /> A <br /> N ISTAT ZIP CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, ETC. t�v <br /> FACILITY FEE = 5100.00 each SITE ADDRESS per YEAR TOTAL <br /> A -- <br /> C 1906 1981 1988 1989 <br /> T <br /> E TANK FEE = $50,00 each TANK <br /> F 1 Tanks _ x 550.00 1986 1987 1988 1989 <br /> A lmultipTy ( by fee for <br /> C each year applicable) d art f ,z' r <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Set 25287 for applicability) <br /> 1 <br /> T 1 Tanks x $56.00 1986 1981 1908 1989 <br /> Y (enter iiount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal 6T Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANKS x $90.00 $ <br /> UP1 in �, <br /> R TEMPORARY CLOSURE (Only allowed one time for iovi 6a, S <br /> Nrt�yERVICES <br /> E Ht'A <br /> TEMPORARY CLOSURE FEE = $80,00 each TANK 1 Tanks x $80.00 t <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> H PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK 1 Tanks <br /> E x $110.00 t <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> _ <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 = $35.00/hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> my agloginglivi I <br /> SWEEPS 1 COMP 1MCODEDIST AMOUNT DUE AMOUNT RCVD CHECK /CASH RCVD BY�'l lilpJa H IAAIA I I <br /> �Iluul nmVllumoluuDomrmu;N,Iurm <br />