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onlyAwullw LUGAL HEALTH DI ICT _ *GROUND STORAGE TANK PROGRAM - FEE WORKSHEEE A FACILITY/SITE NAME — FACILITY CONTACT NAME — j' L STREET ADDRESS SITE PHONE I WITH AREA CODE I T Y CITY STATE ZIP CODE t of Tanks at Site AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME — P I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE C A --- __ N CITY STATE ZIP CODE TYPE of APPLiCAT10N T CLOSURE. INSTALLATION, ETC. FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR — TOTAL A — --- — --- -- --- --- -- ----- —— —— C 1986 1987 1988 1989 T —--- — V E TANK FEE _ $50.00 each TANK F I Tanks ultiply I-h_ x (50.00 1986 1987 1988 1989 A (my fee C each year applicable) I - LCL. GC L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) I — --— — — — T I Tanks x $56.00 1986 1981 1988 1989 Y (enter z,666t and year — � L PERMANENT CLOSURE (Removal or Closure-in-place)---- — y Tv+v v':O 9 CLOSURE FEE = $90.00 each TANK I Tanks__ x t*6 f— — U - _j::1 _— a— ---_-_ R TEMPORARY CLOSURE (Only allowed one time for up to two years) Ut — EP — E —_ TEMPORARY CLOSURE FEE = $80.00 each TANK _---- — �( t Tanks — x $80 C\M R�\ P PLAN CHECK (Installation or Repair) — L'— -- A N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION f REPAIR R TANK REPAIR FEE = $110.00 each TANK I Tanks x $110.00 f — — E-- -- P — A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION — (when applicable) (when applicable) (when applicable) FEE = 130.00/hr FEE _ $35.00/hr FEE = 135.00/hr $ TOTAL DUE OFFICE USE ONLY — Ing SWEEPS I COMP I LOC CODE DIST CDDE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BYDATE RECEIVED PERMIT I • NMI going •