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anhAuully Lus:AL HEALTH DIc RICT2 <br />�IIDERGROUND STORAGE TANK PROGRAM - FEE NORKSH& k <br />F <br />FACILITY/SITE NAME <br />FACILITY CONTACT HAKE <br />A <br />t <br />1 Tants 1 1110.00 <br />C <br />A <br />-- <br />L <br />STREET ADDRESS <br />SITE PHONE 1 WITH A.m. too! <br />1 Tants 1 190.00 <br />�f Ske_� N <br />C <br />T <br />1986 <br />1907 <br />1988 <br />1909 <br />Y <br />CITY✓ <br />STjT <br />IIP CODE <br />I of Tants <br />C <br />I <br />at Site <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />�O G t '?c� G <br />V <br />P <br />L <br />I <br />MAILING ADDRESS <br />APPLICANT PHONE 1 WITH ..fA cove <br />C <br />F <br />A <br />C <br />1 Tants1 $50.00 <br />(multiply -I_ by fee for <br />each year applicable) <br />1906 <br />N <br />CITY <br />STAT <br />IIP CODE <br />TYPE of APPLICATION <br />CLO.W.e, 104T.LL.110M. 11C. <br />C <br />FACILITY FEE _ $100.00 each SITE ADDRESS <br />per YEAR <br />t <br />1 Tants 1 1110.00 <br />TOTAL <br />A <br />-- <br />0 <br />CLOSURE FEE _ $90.00 each TANK <br />1 Tants 1 190.00 <br />$ <br />C <br />1986 <br />1907 <br />1988 <br />1909 <br />U <br />f <br />R <br />TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br />E <br />I <br />TEMPORARY CLOSURE FEE _ $80.00 each TANK <br />ants 1 580.00 <br />is <br />'•D �% <br />�O G t '?c� G <br />V <br />E <br />TANK FEE a $50.00 each TANK <br />F <br />A <br />C <br />1 Tants1 $50.00 <br />(multiply -I_ by fee for <br />each year applicable) <br />1906 <br />1987 <br />1980 <br />1989 <br />) <br />S v <br />$ U <br />1 <br />L <br />STATE SURCHARGE a $56.00 each <br />TANK (see <br />CA HEALTH L SAFETY <br />CODE Set <br />25181 for applicability) <br />I <br />T <br />Y <br />1 Tants 1 156.00 <br />(enter Mount and year) <br />1906 <br />1987 <br />1980 <br />1909 <br />_T6 <br />$ <br />C <br />PERMANENT CLOSURE (Removal or Closure -in-place) <br />UIV131" <br />t <br />1 Tants 1 1110.00 <br />L <br />PLAN CHECK FEE a $30.00 each SUBMISSION/RESUBMIS NAR <br />IN COUNTY <br />S <br />0 <br />CLOSURE FEE _ $90.00 each TANK <br />1 Tants 1 190.00 <br />$ <br />FEE _ $30.00/hr <br />- - <br />S <br />U <br />R <br />TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br />E <br />TEMPORARY CLOSURE FEE _ $80.00 each TANK <br />ants 1 580.00 <br />is <br />MY v MGry I <br />P <br />PLAN CHECK (installation or Repair) RECEIVED <br />UIV131" <br />t <br />1 Tants 1 1110.00 <br />N <br />PLAN CHECK FEE a $30.00 each SUBMISSION/RESUBMIS NAR <br />IN COUNTY <br />S <br />REPAIR <br />ENVIRONMENTAL HEAL I 1i <br />UIV131" <br />R TANK REPAIR FEE a $110.00 each TANK <br />1 Tants 1 1110.00 <br />t <br />E <br />P <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour <br />— <br />to be paid on plan submittal) <br />I <br />k UNAUTHORIZED RELEASE EVALUATION <br />(when applicable) <br />CONSTRUCTION INSPECTION <br />(When applicable) <br />SAMPLING INSPECTION <br />(when applicahlel <br />FEE _ $30.00/hr <br />FEE _ $35.00/hr <br />FEE _ $95.00/hr <br />f <br />TOTAL DUE <br />OFFICE USE ONLY <br />SWEEPS 1 I COMP 1 ILOC CODEIDIST CODEI AMOUNT DUE I AMOUNT RCVD 1(_�ICK)/CASH I RCVD BY I DATE RECEIVED I PERMIT 1 <br />