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gully Lut;AL HtHLTH DISI C1' (� <br /> UNOUND STORAGE TANK PROGRAM - FEE WORKSHEET 0 ' <br /> rEADD Y/SITE NAME 0 <br /> FACILITY CONTACT NAME (� <br /> DDRESSi/��/11``--jj yA4p r(jo SITE PHONE t WITH ARK- CODESTAT ZIP CODE t of Tanksat Site <br /> T/BILLING NAMEAPPLIChNT CONTACT NAME <br /> DDRESS APPLICANT PHONE t WITH AREA CODE <br /> STAT ZIP CODE TYPE of APPLICATION <br /> CL011 INSTALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C 1986 1981 1988 1989 <br /> T <br /> I <br /> V f —10 <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks j x $50.00 1986 1981 1988 <br /> A (multiply I by fee for <br /> 1989 _ <br /> C each year applicable) < — <br /> �C' <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25281 for applicability) <br /> 1 <br /> I 1 Tanks x f56.00 1986 1981 1988 <br /> Y (enter a�ount and year) 1989 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L �_ <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> S 1 Tanks x <br /> U $90.00 $ <br /> R TEMPORARY CLOSURE (Only allowed one ti <br /> E me for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK <br /> t Tanks____ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> f <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK <br /> E I Tanks x $110.00 $ <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, mi <br /> I nimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (when applicable) (when applicable) SAMPLING INSPECTION <br /> (when applicable) <br /> FEE = $30.00/hr FEE = f35.00/hr <br /> OFFICE USE ONIY <br /> TOTAL DUE <br /> !111 a II 111 1 <br /> 1 ' 1I 111 I 1 1 11 I 'I I'I. I 1p I ql Iq! <br /> SWEEPS i COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT t <br /> ''°'ll'I"I:"Ilyl!tltll�'IIIIViI,I���''1���Ip� ^Itll! Itl �IIIVIINIIIWIIIIIIIItlIiIIlilVlil'lip(CInpIIIIPI` <br /> 2 2Z EVTSEq�g — tllllill I' III I 1! 11 1111 ,1 III I! IIIIII 11 VI tlpn nn1 <br />