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onAv .-Ulgaaully LUGAL HEALTH DI^1'KICT <br /> .� ERGROUND STORAGE TANK PROGRAM - IEE WORKSHLz✓ <br /> f FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> 1 \/k?E' 2rS Th , s irl :SsiOY► S '� / �/ <br /> (.L G6 l i til�C� Gam_ <br /> L STREET ADDRESS SITE PHONE 1 we*x w[c• coot <br /> T � r"7 c--e-' C�O 9of — 3 Z 3 <br /> Y CITY C / STAT ZIP CODE 1 of Tanks <br /> /)7 � C K pY} 10 at Site <br /> A APPLICANT/BILLING NAME <br /> PAPPLICANT CONTACT NAME <br /> - <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> A <br /> T CITY �'`� �' AT 2[P CODE TYPE of APPLICATION <br /> ri �](y closullE. In[T�II�rIDM. [TC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A - <br /> C <br /> T 1986 1987 1988 1989 <br /> 1 <br /> V f <br /> E TANK FEE _ $50.00 each TANK <br /> I 1 Tanks 1 $50.00 1986 1987 1988 1999 <br /> A (Uullipiy 1-by fee for <br /> C each year applicable) <br /> I <br /> 1 I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH L SAFETY CODE Set 25287 for applicability) <br /> I <br /> T 1 Tanks �- x 456.00 1986 1987 1988 1909 <br /> Y (enter iiboht and year) <br /> CPERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> O CLOSURE IEE = $90.00 each TANK 1 Tanks x 190.00 <br /> S $ <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 <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 $110.00 <br /> E f <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 /> IEE = 430.00/hr FEE = $35.00/hrIEE = $35.00/hr <br /> _ f <br /> DffftE USE ONLY TOTAL DUE <br /> ul-0 <br /> 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK ASH RCVD BY DATE RECEIVED PERMIT 1 <br /> nI <br /> wWWYYYYypyyyyyyl III 1 1 1 In,••ml II I <br />