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only JUAWU1e4 LUCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> I I)A LF L)ru <br /> L STREET ADDRESS SITE HONE # WITH AREA CODE <br /> I D (p <br /> T <br /> Y CITY STAT Z[P CODE # of Tanks <br /> at Site Z <br /> A APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> A <br /> N CITY STAI ZIP CODECL BUR PPLICATION <br /> T /-20 INSTALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> T 1986 1987 1988 1989 <br /> 1 f _- <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanks -1-by <br /> �_ x (50.00 1986 1987 191 1989 <br /> A (multiply t by fee for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T # Tanks x $56.00 1986 1981 1988 1989 <br /> Y (enter mount and year) <br /> �"7a - <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L - - <br /> O CLOSURE FEE _ $90,00 each TANK # Tanks <br /> S __ __ x $90.00 $ 9 U <br /> — <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 x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L — <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK # Tanksx $110.00 f <br /> E - - <br /> P - — <br /> A PIPING REPAIR/CLDSURE/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 - is <br /> TOTAL DUE is <br /> OFFICE USE ONLY <br /> SWEEPS # COMP i LOC CODE D[ST CODE AMOUNT DUE AMOUNT RCVD ECK CASH RCVD BY DATE RECEIVED PERMIT # <br /> i; =mom mak M) <br /> r.s 6 <br />