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onh ., UAwU1,4 LOCAL HEALTH DISTRICT <br /> L` 0OUND STORAGE TANK PROGRAM - FEE WORKSHEEL. <br /> PAI)LITT/SITE NAME FACILITY CONTACT NAME <br /> Sc-eV/6 lRV �2vt�E� <br /> L STREET ADDRESS SITE PHONE 1 WITH ARCA CODE <br /> Y CITY STAT ZIP CODE i of Tanks / <br /> at site <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> 5C--RL/ c N W�sl� Dv3asc <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> C 2 S 2p a <br /> A <br /> N CITY STATd ZIP CODE ITYPE of APPLICATION <br /> T / CLOSURE, IMSTRLLRTIOM. ETC. ^ <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 4986 1981 1988 19 'i <br /> I f <br /> V - <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks _ x $50.00 1986 1981 1988 1989 <br /> A (EUltipfy I by fee for <br /> C each year applicable) $ <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH l SAFETY CODE Sec 25281 for applicability) <br /> 1 <br /> T I Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter mount and year) <br /> $ <br /> ETEhPORARY <br /> ENT CLOSURE (Raillowedone <br /> in-place) <br /> E FEE _ $90.0 1 Tanks x (90.00ARY CLOSURE (One for up to two years) <br /> CLOSURE FEENK 1 Tanks x !80.00 $ <br /> fPPLAN Installationor Repair)E _ $30.00 each SUBMISSION/RESUBMISSION $ db <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK <br /> E 1 Tanks x $110.00 f <br /> P <br /> A PIPING REPAIR/CLDSURE/REMOVAL (Fees are per hour, Einiaus one hour o be paid on plan subsittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FFE _ $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr <br /> _ f Cab <br /> f <br /> OfflCF USE DYIY TOTAL DUE <br /> (ps em <br /> L CI, i, it I •. a6 :,I- •rm . l nnli C" m ; +n � ?r,i m; vv" i <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AXOUNT DUE AMOUNT RCVD HECK /CASH KCVO BY DATE RECEIVED PERXIi t <br /> r/..- I,: <br /> /S3 / Chi 33,3 <br /> rra`. IV ::k i. "IAfliK'" <br /> ymMZE' �, n.ilk " ;NI irnirrl, ...n it r i n iii ric / <br /> 3 l" �h ei kq�p�d <br />