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J uAwU 1 w Lut.AL HEALTH DISTRICT <br /> U 3ROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> f �'ACILIIY/SITE NAME _ <br /> A FACILITY CONTACT NAME <br /> C <br /> I <br /> L STREET ADDRESS <br /> nSITE PHONE 1 Y1TN AREA coo[ <br /> T <br /> Y CITY 041,7F) <br /> T 71P CODE i of Tanks <br /> - at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P G(if v G J ew SIL' <br /> L C¢,yl lJ <br /> 1 MAILING ADDRESS <br /> C APPLICANT PHONE 1 WIT" AREA CODE <br /> i <� ' <br /> A Gam, <br /> T CITY STAT IPP CODE TYPE of APPLICATION <br /> 7 CLOtlUA[, IMtlTALLAiIOM, [TC. G U <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> ATOTAL <br /> -- <br /> C 1986 1987 1988 1989 <br /> T <br /> V f <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks _ z $50.00 1986 1987 1988 1989 <br /> A (suItipiy 1 by fee for <br /> C each year applicable) $ <br /> l <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> ,T 1 Tanks z $56.00 1986 1987 1988 1909 <br /> Y (enter Mount and year) <br /> 1 <br /> IC PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK -1 Tanks ---- <br /> z (90,00 $ <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80,00 each TANK 1 Tanks _ x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUBMISSION <br /> $ <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK 1 Tanks_:_ z (110.00 $ <br /> E �U <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 UNAUTHOR17ED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when appli(able) (when applicable) (when applicable) <br /> FEE = $30.00/hr FEE = $35.00/hr /vtiij. FEE _ $35.00/hr $ 70 <br /> OFFICE USE OILYTOTAL DUE : <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD DY DATE RECEIVED PERMIT t <br /> I'I IIryT'71 N� �I � <br /> I Illllltllll I� ! <br /> i.l7aill►udituu,,;ulonaG�n� I�iior�����uii,i m l <br />