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4 UAWU 1 iv LUGAL HEALTH DISTRICT <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br /> rA F F:;CI'LITYlSITE NAME FACILITY CONTACT NAME <br /> I J� � SSc� c <br /> L STREET ADDRESS n _ <br /> 11, ��?C � � rn � �� SITE PHONE 1 "IT" ^,cA coot <br /> Y CITY <br /> :7APPLICANT <br /> i °of Tanks <br /> a� Site <br /> A APPLICANT/BILLING NAME <br /> P CANT CONTACT NArrR A Y M E M T <br /> L REd,EF <br /> [ MAILING ADDRESS R E C E I V E D PHONE I <br /> C <br /> CITY FEB 7 Q FTYPE of A <br /> �o.��t, f� AL HEALTH <br /> A <br /> FACILITY FEE = $100.00 each SITE C '� TOTAL <br /> 1986 . <br /> T 1987 1988 1989 f <br /> I _ <br /> 10 0 <br /> E TANK FEE _ $50.00 each TANK <br /> r i Tanks _ a $50.00 19BG 1981 <br /> A (multiply- r by fee for 1988 1989 <br /> C each year applicable) —--� <br /> I �o $ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25281 for applicability) b <br /> T I Tanks a 156,00 198G 1987 <br /> Y (enter mount and year) 1988 1989 <br /> S <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK <br /> S I Tanks 0 1 <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) f' <br /> E <br /> TEMPORARY CLOSURE FEE = $80,00 each TANK <br /> 0meq 00� $ <br /> P PLAN CHECK (Installation or Repair) <br /> A �1L y 'SE,Nry <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK <br /> I I Tanks <br /> P - <br /> A PIPING REPAIR/CLOSUREIREMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (when applicable) SAMPLING INSPECTION <br /> (,Then applicable) <br /> (when applicable) <br /> FEE -- 1�D.0o/hr FEE _ $35,00/hr <br /> FEE _ $3,,,OOlhr $ <br /> QF{!CF 11SE ONLY TOTAL DUE 3 /5,0100 <br /> 71 ^II I' <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD HICK (CASH RCVD BY DATE RECEIVED <br /> ry��I ' l�fe�',•It3r� _ ,�j Z3 /50 . 00 <br /> PERMIT I <br /> r.� , +illull 131 II�,�I:. If I�I I'. i " ull I " TIN I fll l�IM Ilex 7 5© , a O 3q 3 <br /> �� 4 r f l� i � I�Ir l Pflllr' " I' I'!. '!" I I I'",IIP!I, 1fI glpll n I G �i��r'IIII����It11r�11R1i�1�1i <br /> rllp IaII�6;�i11�.�. <br />