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JR/V wu 1 iv Lut;AL HEALTH D Y Sf l CY <br /> I GROUND STORAGE TANK PROGRAM - FEE 6ORKSHEET <br /> 'F FACILITYISITE NAME FACILITY CONTACT NAME <br /> c FR A►'U <br /> 1 <br /> L STREET ADDRLi ESS 511E PHONE MITM ARCA cont <br /> T <br /> Y CITYZIP CODE <br /> 01 4,t +e e c-c— �5 33(o atoSitenks <br /> A APPLICANTIDILLING NAME APPLICANT CONTACT NAME <br /> F ±P—rr © re.. <br /> L <br /> I MAILING ADDRES APPLICANT PHONE IL MITM AREA CODE <br /> C5fcch.f' abs O7 <br /> A <br /> N CITY / STAId 21P CODE I TYPE of APa4trM, 7- <br /> T �t (f i- f,w _ 04rt (1 CLOMURE, aTALLAaroYF, TC. 3 <br /> FACILITY FEE = 3100.00 each SITE ADDRESS per YEAR o TOTAL <br /> A-- - <br /> T 1'986 1987 1988 1989 <br /> I <br /> v <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks _ x $50.00 198fi 1987 1988 1989 <br /> A foultiply F by fee for <br /> C each year applicable) 3 1 0— <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks„3 x 356.00 1986 1987 1988 1989 <br /> Y (enter count and year) r <br /> G �� <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK I Tanks x 190.00 3 <br /> S ------ <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $00.00 each TANK I Tanks x $60.00 3 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION 1 ,� <br /> REPAIR -- <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x 3110.00 S <br /> E ------ <br /> P <br /> A PIPING REPAIRICLOSUREIREMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHOR17ED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.001hr FEE -- $35.00Ihr FEE = 335.00/hr S <br /> TOTAL DUE $ <br /> OFFICE USE ONLY *`05073 <br /> VSWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO CHECK IICASH RCVD HY DATE RECEIVED PERMIT I <br /> 0 73 <br /> NI � <br /> O <br />