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SAMob QUI M LOCAL HEALTH DIEWCT l--jgb6- 3� <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> 1 tt L� !t T1� ; - T <br /> L STREET ADDRESS SITE PHONE # (with Area Code) <br /> T <br /> Y CITY STAT£ ZIP CODE # of TANK'S <br /> at Site <br /> A APPLICANU BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P k%5 <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # (with Area Code) <br /> C -7 E I 9 t <br /> A <br /> N CITY g�TEJZIP CODE TYPE of APPLICATION f'i Pt t <br /> T 3 (Closure, Installation, etc.)ptg. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 $ <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F # Tanks x $50.00 1986 1987 1988 19313 <br /> A (multiply-i-by fee for <br /> C each year applicable) $ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH h SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T # Tanks z $56.00 1986 1981 1988 1989 <br /> Y (enter auount and year) <br /> .f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK , Tanks 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 # 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 $ o� <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK # tanks z $110.00 $ <br /> p ----- <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimus one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE _ $35.00/hr 3 Q FEE _ $35.00lhr $J <br /> TOTAL DUE f E °� <br /> OFFICE USE ONLY <br /> IMUMM mass= <br /> ?° <br /> SWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO CHECK #/CASH RCVD BY DATE RECEIVED PERMIT # <br /> '�:ae.y.. .o -.. .: ,y ,. , ,r. ...�'Naas;.:� . t, ..;: fk5'�•t kuPF '. ,a(e.a .'�+.x w rti vets- e 1 ,., -.; :p.r _Y. 1 r g . r. .:.-. <br /> 4 <br /> 1 <br />