Laserfiche WebLink
onw ae,eulw LuGAL HEALTH DIS -.1ICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME <br /> AFACILITY CONTACT NAME <br /> ` <br /> C 0 H t-i ht S Te)C PrLA <br /> ) <br /> L <br /> 1 STREET ADDRESS // SITE PHONE 1 WITH AREA CODE <br /> T <br /> Y CITY STAT IIP CODE f of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> EflAILING <br /> ADDRESS APPLICANT PHONE 1 WITH ARCA COD! <br /> STAT IIP CODE TYPE of APPLICATION <br /> CLOBORC. /WRTALLATIOH. CTC. <br /> A <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR j TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> DD f <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks 5x (50.00 1986 1987 1988 1989 <br /> A (multiply I by fee for <br /> 1 each year applicable) <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH b SAFETY CODE Sec 25287 for +applicability) <br /> I <br /> T 1 Tanks _ z $56;e <br /> 00 1986 1987 1988 1989 <br /> Y (enter imount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK t Tanks x $90.00 f <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 z $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK <br /> E 1 Tanks z (110.00 $ <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 CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE _ (35,00/hr $ <br /> OIflCf USE ONLY TOTAL DUE <br /> I'mrl P er �. e, w". II <br /> �� �ml 'A I I �'• ki � 19111 'I',IN'fl L1°If IM II!I'Rrin' 1 I III"'tl n . 'J !� '�'a II III I...:H11 <br /> SWEEPS i COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT t <br /> i <br /> 'I,Ixr' mlTr' 9'1' HH p lie 111 pnu .. .; 00 <br /> f"y: 111111e;:u"IIA"I IRI Gel.'I,Llu:7FItIIIIIhRaue ,^71+ i uro�rp� "nlmuralrn Inl' �I I mr <br /> 3-877�"RE>�B SIC I JII ' 17IILIUuD,tlIL^tur'IIIIMIIIIIf II'9plPyyllnl II qrp,'. i 11 rupnyI nrm 'n Ilirl � <br /> I �h � I! ' Nf G(I %tfr.d a IILJe„1111 llt'l'. <br /> J <br />