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iDn�V JUAWUOLUCAL HtALTH UISIKICI• <br /> fAL'IlI1YISIIE NAME UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> rFACILITY CONTACT NAME <br /> I 70—L <br /> STREET AODRFSS <br /> f SITE PHONE t (with Area Code) <br /> CITY - <br /> D <br /> 716 STATE ZIP CODE 1 of TANK'S <br /> APPLICANT/BILLING NAME at Site <br /> APPLIC T CON CT NAME <br /> MAIL NG AD ESS / <br /> (� ' APPLICANT P1N)NE t (with Area Code) <br /> CITY ►� O °F- ! - <br /> �, r rL STATE UP CODE TYPE of APPLICATION <br /> <,` (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR Ijl <br /> 1986 TOTAL <br /> 1987 1988 1989 !I <br /> 1 . <br /> TANK FEE = 550.00 each TANK f RECEIVED ,'_ <br /> 1 Tanks _ _ x (50.00 1986 1Qy <br /> (multiply ( by lee for 1981 1988 1989 <br /> each year applicable) i <br /> STATE SURCHARGE = 456.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25281 for applicability) 7H <br /> Go <br /> 1 Tanks x 456.00 1986 <br /> (enter Amount and year) 1981 1988 1989 <br /> $ <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> i <br /> CLOSURE FEE = 490.00 each TANK <br /> 1 links-./-- x 190.00 f <br /> TEMPORARY CLOSURE (Only allowed one time for up to two years) ~ ✓ <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK <br /> 1 Tanksx $80,00 <br /> PLAN CHECK (Installation or Repair) II <br /> PLAN CHECK FEE = 430.00 each SUBMISSION/RESUBMISSION <br /> f <br /> 2EPAIR <br /> IANK REPAIR FEE _ $110.00 each TANK <br /> I tanks_ x (110.00 f <br />'IPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to he paid on Plan submittal) <br /> INAUTHORITED RELEASE EVALUATION CONSTRUCTION <br /> when aPplicable) INSPECTION SAMPLING <br /> EE = 130.00/hr INSPECTION <br /> FEE _ $35.00/hr FEE = 435.00/hr <br /> f <br /> FFICE USE ORLY TOTAL DUE 1 0 <br /> EEPS 1 COMP I LDC CODE DIST CODE AMOUNT DUE AMOUNT RCVO CHECK 1/CASH RCVD 8Y DATE RECEIVED PERMIT 1 <br /> MWAM <br /> OC�t �bO -I�-kS <br />