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bAN -suAUUIN LUCAL HEALTH DIP1RICf <br /> �%AEROROUND STORAGE TANK PROGRAM - FEE WORKSHE1/ <br /> F FACILI Y/SITE NAM FACILITY CONTACT NAME <br /> A <br /> I <br /> L ST ADDRESS SITE PHONE I (with Area Code) <br /> T /b <br /> r <br /> Y CITY G d <br /> STATE IIP CODE I of TANK'S <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> PS A �7A <br /> P <br /> L <br /> 1 MAILING ADORE n APPLICANT PHONE t (with Area Code) <br /> C YJ <br /> A <br /> N CITY ^ STATE ZIP CODE TYPE of APPLICATION <br /> i j A (Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> I ✓ $ b p°� <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks f x $50.00 1986 1987 1988 1'339 <br /> A (multipTy i-by fee for <br /> C each year applicable) ✓ ✓ f <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks ( x 156.00 1986 1987 1988 1989 <br /> Y (enter iiouit and year) <br /> g bo <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 S CLOSURE FEE = $90.00 each TANK N Tanks x (90.00 f <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 t Tanks x $80.00 f <br /> P LPLAN CHECK (Installation or Repair) <br /> A <br /> H PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> R REPAIR <br /> E TANK REPAIR FEE = $110.00 each TANK I Tanks x $110.00 f <br /> p - -- <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = $30.00/hr FEE = $35.00/hr FEE _ $3570/hr f <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT t <br />