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:...�� 0Haaulw LUCrsL Ht-ALTH DI*ICI' <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> lA fACISEfPL <br /> FACILITY CONTACT NAME <br /> h' nSTS SITE PHONE I NITN ARCA coot <br /> TGG:% Sy ,�f IZr;Y CITYSTAT 11P CODE 1 of Tanks <br /> �, y�� f� �� at Sile <br /> PAPPLME APPLICANT CONTACT NAME <br /> L <br /> I MAILAPPLICANT PHONE 1 NIT" ARCA cuuc <br /> C <br /> A <br /> N CITY STAT 11P CODE TYPE of APP <br /> 1 tLNNYA[. "mTALLATJCN� RTC. � <br /> /VO��._�/ 7r <br /> FACILITY FEE = 4100.00each SITE ADDRESS per YEAR TOTAL <br /> A -- <br /> C 1986 190] 1988 1989 9 6)i� <br /> f <br /> 1 <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> f 1 Tanksz 450.00 1986 1987 1988 1989 'J U <br /> A Iwltlpfy I-by lee lot' <br /> C each year applicable! <br /> 1 �l <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH f SAFETY CODE Sec 25281 for applicability) <br /> I <br /> T I Tanks : 156.00 1986 1981 1988 1909 <br /> Y (enter liouit and )ear) <br /> 1 fib' <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks z 190.00 f <br /> S <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 1 Tanks z $80.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> M PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBNISSION <br /> REPAIR <br /> R TANK REPAIR FEE = 4110.00 each TANK <br /> E I Tanks z 1110.00 1 <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 appli(able) <br /> FEE _ $30.00/hr FEE = $35.00/hrFEC = 435.00/hr <br /> _ f <br /> TOTAL DUE <br /> OfflCf USE ONLY <br /> I 1 •' I I <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT <br /> ��Al ,„ / - ✓ ✓ i -�W <br /> 1 <br /> RR <br /> I itl Illnl.y .I h II 'I �.Ip�lA. <br />