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only vullyCl' <br /> LUGAL HEALTH DI *1C <br /> LWGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> 0S 1 i�c <br /> I <br /> L STREET ADD ESS <br /> Sf 1E PHONE I WITH AREA CODE <br /> i L - p S f 'ae� <br /> Y CITY / STAT ZIP CODE I of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA Coot <br /> C <br /> A <br /> N CITY STAT ZIP CODE TYPE of AP LATt11R-� <br /> GLO..ACI mi ALLw11 )N eye. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C 1906 1901 1988 1909 <br /> T <br /> Is <br /> V U - <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks 150,00 P19E <br /> 198) t9B8 1989 <br /> A IwIUp y "by lee lot <br /> C each year applauble) <br /> 1 <br /> L STATE SURCHARGE = 456.00 each TANK (see CA HEALTH t SAFETY CODE Sec 2528) for applicability) <br /> / ,-) o <br /> I <br /> T I Tanks a (56.00 1907 1988 1989 <br /> Y (enter Mount and Elt <br /> 4 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L _ <br /> 0 CLOSURE FEE = 190,00 each TANK 1 Tanks_ __ a 190.00 t <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK 1 Tants s 480.00 4 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION 11 <br /> REPAIR _ <br /> R TANK REPAIR FEE = 1110.00 each TANK 1 Tanks a 4110.00 <br /> E 4 <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 Ic RCLEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when appli(able) <br /> FEf 130.00/hr fEE = 475.00lhr FEC = 135,00/hr 1 <br /> OFF/Cf USF ONLY <br /> TOTAL DUE <br /> mum <br /> SWEEPS 1 COMP 1 LOC CODE DISI CODE AMOUNT DUE AMOUNT RCVO CHCCK I/CASH ;CV =VED3 y �`�5 <br /> • <br />