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M 114 <br /> JWUUiN LtICAL HEALTH DISTRICT <br /> RGROUND STORAGE TANK PROGRAM - FEE WORXSIWS .......... ........... <br /> FATILITYISITE NAME FACILITY CONTACT NAME <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> CITY STATE ZIP COOP s <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L 14 'J <br /> I MAIL NG AADRESS APPLICANT PHONE I "T" AREA CODE <br /> A <br /> N CITY STAT Z1P CODE TYPE of APPLICATION <br /> CLOWNE, IN4TALLATIan, ETC, <br /> FACILITY FEE $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1966 1987 1981 1981 <br /> TjI TANK FEE S50.00 each TANK <br /> F I Tanks x 150.00 1386 1187 1988 1489 <br /> A (mujtipry by fee for <br /> is each year aPD1icable) $ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> I I Tanks x $56.00 1306 1997 1188 1989 <br /> Y (enter iim-ou-fl-t and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $30.00 each TANK <br /> S I Tanks-,2 <br /> x $90.00 <br /> U <br /> P TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $00.00 <br /> —--------- <br /> P PLAN CHECK (installation or Repair) <br /> L:- <br /> A <br /> III PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> PTANK REPAIR FEE = $110.00 each TANK x 1110.00 <br /> E- ............... <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 010.0 FEE = $35.00/hr FEE $35. 0�hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> 7'— <br />