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jn+v j uAwu l or Luk;AL HII:ALTH D I ''R I CT <br /> *RGROUND STORAGE TANK PROGRAM - FEE WORKSHE <br /> F fCCLITY/SITE NAME FACILITY CONTACT NAME <br /> 0 k�ecn !der Ssu c <br /> L STREET ADDRESS <br /> 1 '�5 SITE PHONE 1 WITH AREA cant <br /> /')'1 e S f- <br /> T <br /> Y CITY v <br /> T T IIP CODE I;of Tanks �. <br /> ai Site <br /> A APPLICANT/BILLING NAE APPLICANT CONTACT HAM <br /> P FPAYMENT <br /> P RE IV <br /> C MAILING ADDRESS RECEIVED APPLICANT PHONE wl A <br /> A <br /> T CITY FEB 2 8 1990 STAT I1P CODE TYPE of A <br /> I <br /> T CLOM6JA[, liEQ4 L HEALTH <br /> A-FACILITY FEE = 1100.00 each SITE ORMPF SIR ES TOTAL <br /> - <br /> C 1986 1981 1988 1989 <br /> T <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks Lz 150.00 1986 1981 1988 1989 <br /> A (multipry 1-by fee for <br /> C each year applicable) 1 <br /> I tE;'C) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH i SAFETY CODE Sec 15287 for applicability) <br /> I <br /> T I Tanks Y $56.00 1986 1981 1988 1909 <br /> Y (enter ii�ount and year) <br /> S <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> O CLOSURE FEE _ $90.00 each TANK <br /> S 1 Tanks 0 1 <br /> - --- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) f`F <br /> E fvp <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK ay �r 0� $ <br /> P PLAN CHECK (Installation or Repair) .4/ <br /> L <br /> A <br /> N PLAN CHECK FEE = 130,00 each SUBMISSION/RESUBMISSION N 1 <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK I Tanks x t110.00 <br /> E - ; <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> ------------ <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> when applicable) (when applicable) (when applicable) <br /> FEE = 670.00/hr FEE = $35.00/hr FEE = $35.00/hr ; <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> I I I I <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD HECK !CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 17VI I 1<lel. 8 3 23 <br /> I 0 0 3 r1 9 <br /> ' �I r J�������������n h II I II I <br /> f <br />