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ane% d UAWU 1 w LOCAL HEALTH D l'R Y CT <br />r' RGROUND STORAGE TANK PROGRAM - FEE WORKSIM <br />A FACILITY/SITE NAME FACILITY CONTACT NAME <br />STREET ADDRESS SITE PHONE 1 wIT" AREA coos <br />T �t <br />Y CITY c --- <br />STAT ZIP CODE 1 of Tanks <br />7fi r at Site <br />A APPLICANT/BILLING NAME <br />P APPLICANT CONTACT NAME <br />P <br />L <br />I MAILING ADDRESS <br />C APPLICANT PHONE 1 NITH AREA cob[ <br />a <br />T CITY STAT ZIP CODE TYPE of APPLICATION <br />_- CLO®URE. INSTALLATION. Etc. <br />FACILITY FEE = 1100.00 each SITE ADDRESS <br />A <br />per YEAR <br />1 Tanksz $90.00 <br />$ <br />TOTAL <br />C <br />T <br />1986 <br />1987 <br />1988 <br />1989 <br />1 <br />V <br />L <br />$ <br />E TANK FEE _ $50.00 each TANK <br />A <br />N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br />F t Tanks' x s50.00 <br />A (multipry t -by fee for <br />1986 <br />1987 <br />1988 <br />1989 �f <br />C each year applicable) <br />1 <br />R TANK REPAIR FEE _ $110.00 each TANK <br />E 1 <br />� sCi cxa <br />$ <br />L STATE SURCHARGE _ $56.00 each <br />I <br />TANK (see <br />CA HEALTH L SAFETY <br />CODE Set 25287 <br />for applicability) <br />T i Tanks x $56.00 <br />Y (enter iiount and year) <br />1986 <br />1987 <br />1988 <br />1989 <br />r0 <br />(when applicable) <br />(when applicable) <br />FEE _ $30.00/hr FEE _ $35.00/hr <br />FEE = $35.00/hr <br />C <br />L <br />0 <br />U <br />R <br />E <br />PERMANENT CLOSURE (Removal or Closure -in-place) <br />CLOSURE FEE = 190.00 each TANK <br />TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />1 Tanksz $90.00 <br />$ <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />t Tanks x 180.00 <br />$ <br />P PLAN CHECK (Installation or Repair) <br />L <br />A <br />N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br />f mac, <br />REPAIR <br />R TANK REPAIR FEE _ $110.00 each TANK <br />E 1 <br />Tanks x $110.00 <br />$ <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour <br />1 <br />to be paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br />(when applicable) <br />SAMPLING INSPECTION <br />(when applicable) <br />(when applicable) <br />FEE _ $30.00/hr FEE _ $35.00/hr <br />FEE = $35.00/hr <br />$ <br />0-D17C1 <br />z <br />oFFrcf USE ONLY <br />SWEEPS 1COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD <br />CHECK 11CASH RCVD BY DATE <br />I n <br />RECEIVED PERMIT 1 <br />y�Ift <br />