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zi ISOwu 1 or L UCAL HEALTH D I S I CT <br /> AROUND STORAGE TANK PROGRAM - FEE WORKSHEE4 <br /> �F FACIL!IYISITE NAME FACILITY CONTACT NAVE <br /> A p\ ` <br /> L STREET ADORES$ SITE PHONE I WITH ARCA cont <br /> �'. �� � C" <br /> T STAT IIP CODE 1 of Tanks <br /> Y <br /> CITY c .J4 - c'_ at Site ` <br /> AAPPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> 1 MAILING ADDRESS APPLICANT PHONE I WITH ARCA coot <br /> C <br /> N CITY STAT IIP CODET-L <br /> YPE of APPLICATION <br /> T G6URI IN9TALLAIIGN. [TC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> L _ 1986 1991 1988 1989 <br /> II CSU 1 l o C) <br /> v <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks x 150.00 1986 1987 1988 1989 <br /> A (aullipfy�I-by fee for <br /> C each year applicable) _)C) <br /> 1 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks _ L x 556.00 1986 1987 1988 1989 <br /> Y (enter imaunt and year) S <br /> �.� <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> O CLOSURE FEE = 190.00 each TANK 1 Tanks x $90.00 1 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE ; $80.00 each TANK I anksx $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE c $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R TANK REPAIR FEE c $110.00 each TANK I Tank1' , x 1110.00 1 <br /> P <br /> A PIPING REP AIRICLOS'UREIREMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) )when applicable) (when applicable) <br /> FEE c 130.00/hr FEE = 135.00/hr FEE % 135.00Ihr 1 <br /> TOTAL. DUE <br /> OFFICE USE ONLY <br /> I �p1111 11 <br /> SWEEPS 1 COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> IfF <br /> ) <br /> PI `� i, I I I i l m ( '� Ml I I T" II r <br /> III d I I ISI{III n �u fm p I,lIIry`nil..p <br /> II'n.'I '�IIII�III'I•r�t�I�uF•III�I�III'II�Lfllflr.',�_ <br /> /�Ii <br />