Laserfiche WebLink
,,uAwUlw Lut.AL HEALTH DISICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ILITY/SIiE NAME 1 FACILITY CONTACT NAME <br /> ISITE PHONE 1 w"H ARCA cope <br /> L STREET ADDRESS c �� <br /> Y CITY STAT IIP CODE 1 of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P ��� JF Q J CJ�c �n \ <br /> L <br /> 1 MAILING ADDRESS R�APPLICANT PHONE 1 rR AREA cope <br /> C <br /> ASTAT 11P CODE TYPE of APPLICATION <br /> N CITY aooucc. IMYtALLATXOR. Etc. <br /> 1 <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR Bch TOTAL <br /> C 1986 1981 1988 `F989 <br /> I 1 c, <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 TanksY $50.00 1986 1987 1988 1989 <br /> A (multiply f_by fee for <br /> C each year applicable) c> <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks x $56.00 P <br /> 986 1987 1988 1989 <br /> Y (enter iiount and year) $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks____ z 190.00 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks z $80.00 f <br /> P PLAN CHECK (Installation or Repair) PAYMENT <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION APR $ <br /> REPAIR <br /> RTANK REPAIR FEE _ $110.00 each TANK 1 Tanks z ffBWPT SERVICES 1 <br /> E - _ <br /> P <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 = 130.00/hr FEE = $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> SNEEPS 17,co <br /> LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK /CASH RCVDBYDATE RECEIVED PERMIT 1 <br /> 3�� a3 v.� </ -� a i .p � � ,� � o ili i i I I I� �i It iiil p � � i 9 i q.�-.: �o r. � Ini if =11 <br />