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5AOJOAQU I N LOCAL HEALTH 14TR I CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET -- _ <br /> •..._....__...ACILITYISITE.__.___._.._._.NAME.__..._...._.._..._.._-..__...__—..__....._.._..__.._----____._.-___._.__..__..---._______....FACILITY CONTACT..NAME <br /> SITE PHONE I WITH ARICA COD[ <br /> L STREET ADDRESS r-- <br /> T_._.__—._._.___..__.___._...__ ST TE ZIP CODE I of Tanks pAYMI✓TNT <br /> Y CITY k IoN —� � at Site REGIIUED— <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME AU <br /> P <br /> P <br /> TH <br /> I HAILING ADDP,ES� APPLICANT PHONE 4 "'T" ARS day QNMENTAt HEAL <br /> PERMIT�SEQ\ICES <br /> A — --~- —~ -- STATE IIP CODE TYPE of APPLICATION <br /> N CITY CLOOURe, IH9TALLATIOH, lTC. <br /> T <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> A ......... _ _-- ----.._........__._ _......_........__..... _._..__..._........... _._...- __._.. .. <br /> T — 19$6 — 1987 — 138$ —1989 — - — — <br /> 1989 - <br /> V <br /> E TANK FEE = f50,00 each TANK r <br /> UI'ESERVICES <br /> A (su l t i p Ty <br /> ...._...._._.__....._......._.._..__...._-._._.._......._.....___...... .—_.._.._.___._...___ ..----...__......—._._._ _._.__....._..._.____-----_.._._.....__-•__._._ --•E�lT�C3J1`+7i 7�C�EAt"'i'El�__...___._..._. <br /> F I Tanks _ x 150.00 19$6 1987 1988 1989 <br /> li by fee for _ <br /> each year applicable) 1 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> I T I Tanks C x 156.00 1986 1987 1988 1909 <br /> Y (enter mount and year) — <br /> _.. -- <br /> _..__ ._......_..___.......... <br /> ._._......--— --- <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = 190.00 each TANK I Tan Ys----- <br /> _ x 190.00 1 <br /> 5 <br /> P. TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK I Tanks x 180.00 � <br /> _.........I.........._ ...._ .,_. <br /> P PLAN CHECK (Installation or Repair) _ <br /> L —............ — <br /> A <br /> N PLAN CHECK FEE = 130.00 each SUDMISSIONIRESUDMISS1011 1 <br /> REPAIR <br /> R TANK REPAIR FEE - 1110.00 each TANK -_--� ^ I Tanks x 1110.00 <br /> _-- <br /> A PIPING P,EPAIP,ICLOSUREIP.EMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) -� <br /> T l i c a b l e) When applicable) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (uh en applicable) (when applicable) <br /> FEE 130.001hr FEE 135.00{hr FEE 1�5.001hr 1 <br /> _.__......._._.... .._......._._.__.. __._ _._- ——..__.— _..._......... <br /> _ _.•.___ — <br /> TOTAL DISE 1 — <br /> OFFICE USE ON(y <br /> IF,!xIMP Imp d n CODE I N iUAlElllilli49A0.11� .,axiAR114Ki�q. d i{ �1�1111fImAib 11[Jill. i M . <br /> WEEPS I COMP I LOC CODE 615T AMOUNT DUE AMOUNT RCV CHECK CASH RCVD BY DATE RECEIVED PERMIT # <br /> __..._.—. _..._. _........... <br /> _......_... <br /> 0110f���II�'�11��€9MMMINIPP111i9 Mil 1,1f 1MMMI ffil �i ill <br />