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+amu1+v Lu%;mL HEALTH I <br /> F FACILITY/SITE NAVE <br /> f . GROUND STORAGE TANK PROGRA4 - FEE WORKDSHE <br /> Cl' <br /> A FACILITY CONTACT NAME <br /> I <br /> L STREET ADDRESS <br /> SITE PHONE I WITH AREA cane <br /> T <br /> Y CITY _ <br /> STMT IIP COOS I of Tanks <br /> A APPLICANT/BILLING NAME a t Site <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE I WIIH AREA COOK <br /> A <br /> CITYIT STAT <br /> IIP CODE 1YPE oI APPLICATION <br /> cL,n rUAK. IMat w�Lwt10K, EIC. <br /> F(multipTy-l'by <br /> = 3100.00 each SITE ADDRESS per YEAR <br /> TOTAL <br /> 1986 1907 1989 1984 <br /> I <br /> VaC� <br /> 350.00 each TANK '- <br /> x $50.00 I9O6 1907 <br /> y fee (or1988 1989 <br /> yearapplicable) 7---�-- <br /> �`. <br /> L 5TATE SURCHARGE = 356.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25281 for applicability) <br /> T I Tants x 356.00 1986 1997 <br /> Y (enter a6at and year) 1998 1909 <br /> 3 <br /> 19TWORARY <br /> ERMANENT CLOSURE (Removal or Closure-in-place) <br /> LOSURE FEE = $90.00 each TANK <br /> I Tants x 390.00 ' s <br /> CLOSURE (Only alloyed one ti.e for up to two years) <br /> MPORARY CLOSURE FEE = 380.00 each TANK <br /> 1 Tants 1 300.00 3 <br /> EPLANCHECK (Installation or Repair) <br /> EE = 330.00 each SUBMISSION/RESUBMISSION <br /> HI <br /> ERECII <br /> IR FEE = 3110.00 each TANK <br /> I Tants x 3110.00 s <br /> AIR/CLOSURE/REMOVAL, (Fees are perour, ainiEu■ ane hour to he paid on plan subEiltal) <br /> ED RELEASE EVALUATION CONSTRUCTION INSPECTIONSAMPLING INSPECTION <br /> icable) (when applicable) (when applicable) <br /> 00/hr FEE = 335.00/hr � <br /> FEE = 33,xr <br /> .00/hr 3 <br /> r)ttlfF !!SF Olfil <br /> TOTAL DUE 3 goo K � <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVO CHECK WASH RCVD BY GATE RECEIVER PERMIT 1 <br />