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:+n 8%AwU 1 ev LuCAL HEALTH DIORI CT <br />ORGROUND <br />� w �,�� � . ��� �•, Ie�� d'aGbld � c :N <br />STORAGE TANK <br />PROGRAM - FEE WORKSHEET <br />��,,,,a ' <br />' <br />FACILITY/SITE NAME <br />A <br />FACILITY CONTACT NAME <br />DIST CODE <br />� , <br />C <br />IF <br />RCVD BY DATE RECEIVED <br />—�--- <br />..., �.......... J� ,�... k�-".. jrJ -` L7�'7 J � <br />� /^{,. % X` 7 <br />L STREET WiESS - <br />1 <br />SITE PHONE # WITH AREA Cone: <br />_ _ <br />T <br />Y CITY <br />STAT <br />ZIP CODE <br /># of Tanks <br />_ <br />at Site <br />A APPLICANT/BILLING NAME <br />P <br />APPLICANT CONTACT NAME <br />P <br />L <br />I MAILING ADDRESS <br />C <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />N CITY STAT <br />TR <br />IIP CODE FTYPT[of�APPLICAT�ION <br />1N®TALTION. ETC. <br />FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br />A <br />-- <br />1 <br />T <br />1486 1987 <br />1988 1989 <br />I <br />V <br />— <br />$ <br />EFFEE50.00 <br />each TANKF <br />$50.001986 1487 <br />A fee for <br />1988 2989 <br />C each year applicable) c2i$ <br />1 <br />L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH i SAFETY CODE Sec 25287 for applicability) <br />T I Tanks -4— x $56.00 1986 1987 <br />Y (enter amount and year) <br />198B 1989 <br />5 <br />$ <br />LOSURE (P.esoval or Closure -in-place) <br />FCPERMEANENT <br />= $90.00 each TANK# <br />Tanks 0 <br />ORARY CLOSURE (Only allowed one time for up to two years) <br />E <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br /># Tanks580. <br />_ <br />$ <br />P PLAN CHECK (Installation or Repair) <br />A <br />_ <br />N'PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br />f <br />REPAIR <br />R TANK REPAIR FEE = $110.00 each TANK <br />E <br /># Tanks <br />x $110.00 <br />$P ----- <br />_ <br />A PIPING kEPA1R/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br />I <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br />(when applicable) <br />SAMPLING INSPECTION <br />(when applicable) <br />(when applicable) <br />FEE = f30.00/hr FEE = 435.00/hr <br />FEE = f35.00/hr $ <br />TOTAL DUE $ <br />OFFICE USE ONLY <br />•, , ,,, .,::.W.,:. <br />� w �,�� � . ��� �•, Ie�� d'aGbld � c :N <br />ad'r^► � t �"!II"!I!I!!�6'� <br />!� drya 10j,!, Rrm!.; I n�n�! pd ;i,, C'D , !'n!I !. • I!I" M!' � I� ud �N <br />��,,,,a ' <br />' <br />SUEEPS # <br />COMP I LOC CODE <br />DIST CODE <br />AMOUNT DUE AMOUNT RCVD CHECK I/CASH <br />RCVD BY DATE RECEIVED <br />—�--- <br />..., �.......... J� ,�... k�-".. jrJ -` L7�'7 J � <br />� /^{,. % X` 7 <br />TOTAL <br />PERMIT # <br />