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anewwU l ry LUCAL HEALTH D I S I CT <br />AROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br />FA-FACILITY/SITE <br />NAME <br />FACILITY CONTACT NAME <br />A <br />_ <br /># Tanksj _ x (90.00 <br />C <br />I- <br />NO �iwm <br />1986 <br />L <br />STREET ADDRESS <br />SITE PHONE # WITH AREA COOL <br />I <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />T <br />T <br />Y <br />CITY <br />STAT <br />ZIP CODE <br />LloShlanks <br />e <br />AA <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />TANK FEE = $50.00 each TANK <br />F <br /># Tanks x $50.00 1986 1981 1988 1989 <br />P <br />� <br />Q - <br />L <br />I <br />I <br />MAILING ADDRESS <br />APPLICANT PHONE WITH AREA ..DE <br />A <br />Prz-L <br />NCITY <br />1989 <br />STAT <br />ZIP CODE TYP APPLICATION <br />T <br />(enter awount and year) <br />8UREINSTALLATION, ETC. <br />C <br />L <br />FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br />TOTAL <br />A <br />_ <br /># Tanksj _ x (90.00 <br />C <br />U <br />1986 <br />1981 <br />1988 <br />1989 <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />T <br />$ <br />$ <br />I <br />V <br />E <br />TANK FEE = $50.00 each TANK <br />F <br /># Tanks x $50.00 1986 1981 1988 1989 <br />A <br />(multiply -E -by fee for — -- -- ------ -- <br />C <br />each year applicable) $ <br />I <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25281 for applicability) <br />T <br /># Tanks x $56.00 <br />1986 <br />1981 <br />1988 <br />1989 <br />Y <br />(enter awount and year) <br />$ <br />C <br />L <br />PERMANENT CLOSURE (Removal 6r Closure -in-place) <br />0 <br />S <br />CLOSURE FEE = $90.00 each TANK <br /># Tanksj _ x (90.00 <br />$ <br />U <br />R <br />E <br />TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br /># Tanks x $80.00 <br />$ <br />P <br />L------ <br />PLAN CHECK (Installation or Repair) <br />----- _._� <br />A <br />N <br />PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br />f <br />REPAIR <br />R TANK REPAIR FEE = $110.00 each TANK # Tanks x $110.00 f <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 UNAUTHORIZED RELEASE EVALUATION CON NSPECTION SAMPLING INSPECTION <br />(when applicable) (wh 166 (when applicable) <br />FEE _ $30.00/hr FEE .00/hr FEE _ $35.00/hr f <br />JANv _ 1� TOTAL DUE $W�� <br />OFFICE USE ONLY ENV! RdurgN11ENTAL HEALTH <br />I SWEEPS # I COMP # ILOC CODEIDIST <br />11 <br />AMOUNT DUE I AMOUNT RCVD I CHECK #/CASH I RCVD BY I DATE RECEIVED I PERMIT # <br />