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uE,av .a'0AwU1v1 LUc:HL HEALTH DIS' RICI" <br /> P HD STORAGE TANK PROGRAM - FEE WORKSHEL� <br /> f FACILITY/SITE NAME FACILITY CONTACT NAME <br /> L-,r-x'kTqP � <br /> L STREET ADDRESS SITE PHONE 1 wrrH AREA coca <br /> i :37 4(9 � G e. i9 7 15� 3u <br /> Y CITY ��4 STAT IIP CODE d1of Tanks _3 <br /> 5�' at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P S <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 Hrr« ARCA CODE <br /> AG'LaHE <br /> N CITY STAT IIP CODE TYPE of APPLICATION <br /> T aaeu=E, iHAtAUAn aH. ETC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> - <br /> C 1986 1987 1988 d9B9 <br /> T <br /> V /aa ao io v ;jpv ► /fo D <br /> E TANK FEE = 150.00 each TANK <br /> f 1 Tanks _ a 550.00 1986 1987 1988 1989 <br /> A (mullipfy 1 by lee for <br /> 1 each year applicable) 1,�v �ZJ / <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH k SAFETY CODE ec 25281 for applicability) <br /> I <br /> T 1 Tanks _ m (E 1986 1981 j 1988 1909 <br /> Y (enter imount andC PERMANENT CLOSUREor Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $9TANK 1 tanks_ __ 190.00 1 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to t, o years) <br /> E <br /> TEMPORARY CLOSURE FEE = 580.00 each TANK 1 Tanks a 180.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = 130.00 each SUBNISSIONIRES EMISSION I <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK I Tanks <br /> z SI(0.00 S <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 = 530.00/hr FEE = 535.00/hr FEE = 535.00/hr I <br /> / TOTAL DUE 1 ���j (Jd <br /> OFFICE USE ONLY <br /> SWEEPS I CONP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br />