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SA&CA UIN LOCAL HEALTH &TOLT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> 1• _— �y srlOiJ -2-Ce nOrP �c2, 1Cc Ee/ <br /> ISTREET ADDRESS <br /> T SITE PHONE 1 WITH AREA CODE <br /> Y CITY STATE IIP CODE # of Tanks <br /> ��9SaU at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P _ <br /> P <br /> L C CU <br /> I MAILING ADDRESS -^ APPLICANT PHONE 1 <br /> �_ NITN AREA CODE <br /> y3/ �a r�cG� <br /> N CITY SE Z[P'CODE TYPE of APPLICATION <br /> T /IlodPs� <br /> TAT <br /> .. ,__._•--_---____,�_-_-,,,---. Vy 1 g CLD/UR[. INDTALLATIDN, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR —' '— <br /> a _ -------.._ --TOTAL —-- <br /> C <br /> T 1986 1987 1986 1983 <br /> -- ---T — —�__ _� <br /> I — <br /> E TANK FEE _ $50.00 each TANK -- --- <br /> _--_-.__. . <br /> F 1 Tanks 1 x $50.00 1986 — ---- <br /> 1387 1988 198 — ----�•—�� -._,. <br /> A (multipry 1-by fee for ---- _ <br /> C each year applicable) SoO $ — <br /> 1 .___�_-. - SO apo <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 8 SAFETY CODE Sec 2528 for applicability) <br /> T 1 Tanks x $56.00 1986 1987 1988 1983 <br /> Y (enter ii666t and year) <br /> Gv <br /> C <br /> L PERMANENT CLOSURE (Removal ar Closure-in-place) --- — �--�--�---� �� <br /> ...._- ---- -- ------ — <br /> 0 CLOSURE FEE _ $'30.00 each TANK 1 Tanks / x $90.00 <br /> g...-- — -- L -- $ "� <br /> _ _--- <br /> U — <br /> R TEMPORARY CLOSURE (Onlyallowedone time for up to tv years) <br /> E __ —_ ----------. _.__— —__ <br /> TEMPORARY CLOSUP.E FEE _ $80.00 each TANK 1 Tanks <br /> P PLAN CHECK (Installation or Repair) — — _ — — — <br /> — <br /> A _....--- <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/ SUBMISSION f <br /> kEPAIR <br /> _—.------------ ---- <br /> P, TANK P,EPA(R $110.00 each TA <br /> Tanks_----- x $110.00 f <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 EVALU ION CONSTRUCTION INSPECTION _ SAMPLING INSPECTION — <br /> (when applicable) (when applicable) (vhen applicable) T <br /> FEE _ $30.00/hr FEE = f35.00/hrr— FEE _ $35.00/hr f <br /> OFFICE USE ONLY `/7 TOTAL DUE <br /> P.!@�gq^gqlql ggqqq glgq!I!ql!MI9.�ggFIT'Iqqqqqlqqqq4lm! �IA9flgglPl�q!iiig ggqqCq191!gall!lgl 1g1gq! Igllgq!glgqq!!Iql!! N l 1!q!Ig2!Iq!ggBIGIIG!q:gg1liglqT;i!11j!!1II! I!quTililil@ fllgglV1118gqV!Iq!Igil�flfi!Ilglgll!q Iggl lgghl�IIIIIgGqilliqqlqqqA <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASHVD BY DATE RECEIVEDPERMIT $_...................._........ _. .__...._.._..... -__._..._._.._. ...... _... — EP- 11l!l��hggq,l � !��9�Ilgggll �II�II�IgIIIIIIMIgllll�!ggllll!!91 .VIII!I�fgi��I�gIIIq�V1111g6�1!II:� <br />