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J UAwU 1 Iw LURAL HEALTH DISI cl, <br /> f FACILITY/5f 1E NAME *GROUND STORAGE TANK PROGRAM - FEE WORKSHEE T <br /> _ <br /> C �J FACILITY CONTACT HARE <br /> I STREET ADDRESS <br /> 2� <br /> T 5 j >L SITE PHONE 1 WITH AREA coop <br /> Y CITY <br /> STAT I!P COOE I of Tanks <br /> A APPLICANT/BILLING NAME �_2 �Cc ) at Site <br /> P APPLICANT CONTACT NAME <br /> L 5 <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE I w1TH AREA Coag <br /> A <br /> N CITY <br /> STATE IIP CODE TYPE of APPLICATION f <br /> CLO 011A g. <br /> A INF TALLAlIOM. ETC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR , <br /> --- <br /> f TOTAL <br /> 1986 1981 <br /> I 1900 1999 <br /> V <br /> E TANK FEE = 150,00 each TANK 1 <br /> F 1 Tanks _ 1 110.00 1996 <br /> A (rultipfy f-bY fee for 1981 1988 I909 <br /> C each year applicable) ------ <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25281 for applicability) 1 �.7C <br /> r , <br /> T 1 Tanks----- a 156.00 1986 <br /> Y (enter t and year) 1981 1988 1909 <br /> 1 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = 190,00 each TANK S 1 Tanks x 190.00 <br /> R TEMPORARY CLOSURE (Only allowed one lime for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = 180,00 each TANK <br /> 1 Tanks - <br /> P PLAN CHECK <br /> L (Installation or Repair) <br /> A 6 190 <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSIONv. ulty <br /> SAN JQAQ <br /> REPAIR C HEAT T'!' ,lV <br /> ON <br /> 1 <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> E f Tanks x 1110,00 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees ars per haat, minimum one hour to he paid on Ian_ <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION P submittal) <br /> (when applicable) SAMPLING INSPECTION <br /> (when applicable) <br /> FEE _ $30.00/hr (vfie�?PPlicabJel <br /> FEE = 135.40/hr <br /> FEE=135.00/hr 1 <br /> orria ffSF ONLY TOTAL DUE 1 <br /> � r . <br /> SWEEPS 1 COMP I LOC CODE DIST CODE AMOUNT DUE A CUNT RCVB CHECK I1CA ' r <br /> ---�_ SH RCVD BY DATE RECEIVED PERMIT I <br /> —ted <br />