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r ' QJ-1I�l 'j 'du l IN LuUAL HEALTH D Y SO C1 <br /> UNL`!!I'GROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILI,TYISIIE NAME <br /> FACILITY CONTACT NAME <br /> !�r 2 <br /> L S1fEET ADDRESS - _ } SITE PHONE I wl" AREA coot <br /> I,— Ln L-2 t <br /> Y CITY , , STATZIP CODE IT of Tanks <br /> -c /�_,, - }r., at Site <br /> A APPLICANTIBILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE I WITH ANCA Cnoc <br /> C <br /> N CITY STAT IIP CGDE TYPE of APPLICATION <br /> T CLOOUNEu INSTALLATION, CTC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A-— <br /> C 1986 1987 1988 1989 <br /> T <br /> I <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks �D x $50.00 1986 1987 1988 1989 <br /> A (sultipTy f by fee !or <br /> I each year applicable) ' , i $ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks x $56.04 1986 1987 1988 1989 <br /> Y (enter haunt and year) <br /> C PERMANENT CLOSURE (Resoval or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK I Tanks x $90.00 1 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> ITEMPORARY <br /> CLOSURE FEE = $80,00 each TANK I Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30,00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK I Tanks x $110.00 $ <br /> E <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.001hr FEE = $35.00/hr FEE = $35,OQIhr $ <br /> TOTAL DUE <br /> OFFICE USF ONLY <br /> '� " it r Ali I. 1 I I III I Ir 1 r r iggplaingmjl!PI!��r <br /> SWEEPS I CON? I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK i1CASH RCVD BY DATE RECEIVED PERMIT I <br /> .� rEhli I'I I4�I 1y14ry1111p I�NCr Nlin� ,VI m r I r Ial <br /> r I !; III I� h! A II I rr <br /> f N p I ,IIII� � II 11I I A! �II [ Ir IINI 1 I I'II MI rl 1 I i <br /> ?� r��R,I�YrI�' _ I` f I I I II I, ,�fll #113 N 11 i.." I II I I' II 4 u Itlll I d '•I I�il��lalilrglfF unllll,I ru,,1, <br /> _ 3: 11 Y I h . t. 1 )i.,I,NIdldl��r iol :+.rr llfllihl{II�I�i llll: <br />