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.xUAtuU1M LOCAL HEALTH DISTRICT ` <br /> __ UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SIZE NAME FACILITY CONTACT NAME , ,X d <br /> RMw Truc IRo6eFrr ` 4reue'� ; <br /> L STREET ADDRESS SITE PHONE <br /> I • MI1N AREA CDD[. ,. _ <br /> T - 1-7 rjI eyrr< - <br /> Y CITY � ' .. ' STAT ZIP CODE 1 of Tanks <br /> CA;, 46._3 4 _ <br /> at Site <br /> A APPLICANT/OILLIIA NAME <br /> p APPLICANT CONTACT NAME — <br /> 11 L Oil retie 4 <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> ry. I S AT IIP CODE TYPE of APPLICATION '.Re>u® 1141- <br /> /F CLDDURE, INSTALLATION, ETC.. <br /> I � <br /> FACILITY FEE E 1100.00 each SITE ADDRESS per YEAR ! TOTAL <br /> C - - <br /> T i 1386 1987 I 1988 1983 <br /> I P l <br /> V <br /> E TANK FEE = 150.00 each TANK Q — <br /> F I Tanks s 150.00 1986 1387 1988 - 1983 <br /> A (multiprp-1 by lee for G <br /> C each year applicable)` - I r— <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> 1 1 Tanks x (56.00 1986 1981 " 1988 1383 <br /> Y (enter iioiit and year) — <br /> I 1 <br /> L <br /> SURE (Removal or Closure-in-place) <br /> 130.00 each TANK I Tanks_ 7130.00 f 'dion <br /> SURE (Only allS . owed one time for up to two years) � 'URE FEE = 180.00 each TANK 1 Tanks x 180.00 S <br /> P PLAN CHECK (Installation or Repair) —" <br /> L — <br /> A ----- -- <br /> 11 PLAN CHECK FEE _ ,130.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK +` 1-�— I Tanks x 1110.00 f <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 _ 130.00/hr —__ FEE = 135.00/hr FEE = 135.00/hr 1 <br /> —��__ <br /> TOTAL DUE jai <br /> OFFICE USE ONLY <br /> EM3.41A9PpBRUN 1111 NIIMINI0pNN�Q�I��lllllll�RllllI�iiuiGiViiiiVu�uuViiVi��uliTiiV�IQ ���I�I�I�IIIIINIIII�II�IIII�I011�I� Im�m�O�INI�N�lon�l� I�V�19pfl�I�iH�RIIN�4. <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNNT RC HECK ASH RCVD Y DA1E RECEIVED PERMIT 1 <br /> I. 9 - ��.--�—'— .. <br /> �9NIIMall1�IRn�I11111VI11JIM l 1MIImilul�lllanIII199��MI�ol�llll�ll�l�I�ml� ILII��I�I�IB�MI9�1MfJ01�16 <br />