Laserfiche WebLink
5HN .JfJAUUlN LOCAL HEALTH DISTRICT <br /> OROCRGROUND STORAGE TANK PROGRAM - FEE WORKSHEE.,,� <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> GkJe h _ <br /> L STREET ADDRESS SITE PHONE t WITH AREA CODE <br /> T 12 1 AU C21WCkItLG' (."209 & - <br /> Y CITYS .// II,, _ STAT ZIP CODE t of Tanks 40Yy _ C d at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L — — <br /> 1 MAILING ADDRESS APPLICANT PHONE t WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE] ZIP CODE TYPE of APPLICATION <br /> T CLOSORE. INSTALLATION, ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A-- -- -- ---- — <br /> C 1986 1987 1988 1989 <br /> T <br /> T loo /oo goo <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanksx $50.00 1986 1987 1988 1989 <br /> A (multiplyI_by fee for _ --- — <br /> C each year applicable) S6- <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25281 for applicability) <br /> I --- <br /> T t Tanks___ x $56.00 1986 1987 1988 1989 <br /> Y (enter mount and year) — — <br /> 5�0 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE _ $90.00 each TANK t Tanks _ x $90.00 f <br /> S <br /> U— <br /> E TEMPORARY CLOSURE (Only allowed one time for up to two years) — <br /> --d <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks x $80.00 f <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 i Tanks x $110.00 $ <br /> E -- - <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 = $30.00/hr IFEE = $35.00/hr — FEE = $35_00/hr f <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> CEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT t <br /> 3 <br /> q o — At <br />