Laserfiche WebLink
0"N JtJAWUiry LuGAL HtALrH DISIKICI <br /> UNyC .OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME *FACILITYNAME <br /> A1L SIRE ADDRESS C ZoeI h Area Code) <br /> T Y C1TYr— STATE ZIP CODL <br /> A APPLICANT/B LING NAME APPLI T 74� <br /> CT NAME <br /> P <br /> P r - <br /> FNCITY <br /> LING ADDRESS APPLICANT PHONE f (with Area Code) <br /> c D <br /> ZSTATE Z P CODE TYPE of APPLICATION <br /> C-4 0 (Closure, Installation, etc.) <br /> vv <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C1986 1987 1988 1989 <br /> T <br /> 1 $ <br /> V <br /> E TANK FEE = $50.00 each TANK 'A <br /> F i Tanks _ _ r (50.00 1986 1987 1988 1989 CFS T <br /> A lmultipiy 1 by fee for <br /> C each year aoplicable) 1,1A N <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) IYIV/ 4 ) <br /> T t Tanks x $56.00 1986 1987 1988 1989 F N7q[ <br /> Y (enter iiouit and year) $ /CES <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK t Tanksx $90.00 $ <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 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 <br /> E TANK REPAIR FEE _ $110.00 each TANK t Tanks x $110.00----- f <br /> P <br /> A <br /> 1 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(when applicable) INSPECTION ON <br /> FEE = $30.00/hr FEE = $35.00/hr FEE = $35.00/hr f <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> Z <br /> LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD EC WASH RCVD BY DATE RECEIVED PERMIT t <br />