Laserfiche WebLink
anr% JUAWU114 Lu&;AL Ht-ALTH DIRI'RICI' <br /> 'DERGROUND STORAGE TANK PROGRAM - IEE YORKSK.r <br /> f fALILITY/SITE NAME FACILITY CONTACT NAME <br /> A 7 <br /> C <br /> f <br /> STREET ADDRESS /v SITE PHONE 1 wI*o a[[• toot <br /> Y CITY (D STAT 11P CODE 1 0l Tanks <br /> -� rC at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE 1 WITH •R[• toot <br /> A <br /> N CITY <br /> T 31 11,1 111 CODE TYPE of APPLICATION <br /> OLOtlWK. yen e��en or. [te. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> ATOTAL <br /> C <br /> i 1906 1987 1988 1909 �(] <br /> I <br /> 4 /OD f /00 <br /> E TANK FEE = 150.00 each TANK 9�fQ <br /> r 1 Tanks _ x 150.00 /G C> <br /> A (mul G pIY by fee for 1986 1987 1988 1989 <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> S <br /> T 1 Tanks x 1986 1987 1988 <br /> Y (enter iiount andndyear) 1909 <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tants x 190.00 <br /> S 1 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE c $80.00 each TANK 1 Tanks x 180.00 <br /> 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> f <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK 1 Tanks x 1110.00 <br /> E 1 <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 = 130.00/hr FEE _ $35.00/hr FEE _ $35.00/hr <br /> S <br /> DfflCC USF ONLY TOTAL DUE $ 30tl) <br /> SWEEPS 1 COMP 1LOC CODE DIST CODE AMOUNT DUE AMOUNT CVD CHECK I/CASH RCVD BY DATE RECE14E0 PERMIT 1 <br /> � -- <br /> I�o„Ir^u�� is s <br />