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UNwulw Lu CAL HEALTH DIS <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSHEE 2lCl' <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A 49 wu� <br /> C <br /> L STREET ADDRESS SITE PHONE II WITH AREA CODE <br /> Y CITY /� STAT ZIP CODE It of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P ,D. i� <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AAAA CODE <br /> C <br /> A <br /> N CITY 11 ODE TYPE of APPLICATION <br /> T GLotlU[E. INSTALLATION. [TC. <br /> FACILITY FEE _ $100,W each SITE ADDRESS per YEAR TOTAL <br /> T 1986 1987 198A 1989 <br /> 1 f <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F $ Tanks �_ _ s 450.00 1986 1987 1988 1989 <br /> A (:ultiply t by fee for <br /> C each year applicable) <br /> 1 ✓ i ✓ Is 700 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH f SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks " I $56.00 1986 1981 1988 1989 <br /> Y (enter 55GEt and year) <br /> C PERMANENT CLOSURE (Relioval or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> S 1 Tanks--I--- I $90.00 $ rj <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks I $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK <br /> E t Tanks : $110.00 f <br /> _ <br /> P -- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, miniEum one hour to be paid on plan sub[ittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr FEE = $35.00/hr I FEE = $35.00/hr f <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> II % ......... !! AI I I' I A I''IIIIAW pI I' III"I I!'I 'I III ', I!A'I!' ILI iI lid <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK k/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> Z3 8� 9rft�Sl 5 3 °° - <br /> .I'I I�4(I " IIM1 IflD .ImI k. I Ip a I' SII I A II II qll! III 111 II I" lil!I INV un III tll <br /> Q NI II III P I° 'Anlr ru r,n <br /> ul ryl 1,,.1,I,7G,0<II 91, pJI,IIh.:IIIII x II LI1,h186V11!1;1 <br />