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Qni4 JUAWUlly LUCAL HEALTH DISTRICT &GROUND STORAGE TANK PROGRAM FEE WORKSHE E FACILITY/SITE NAME FACILITY CONTACT NAME A -- L STREET ADDRESS SITE PHONE t WITH AREA CODE Y CITY STATE ZIP CODE t of Tanks i at Site A APPLICANT/BILLING NAME APPLICANT CONTACT NAME P I MAILING ADDRESS APPLICfjdT PH NE i WITH AREA CODE A J C� ,CL✓ltriD^� _ 2r�-I i — N CITY STATE ZIP CODE -TYPE of APPLICATION I ��_- -- CLOSURE. INSTALLATION. ETC. FACILITY TC.FACILITY FEE _ $100.0--0 each each SITE ADDRESS per YEAR — TOTAL A--- ----- 1986 — 1987 - 1988 _1989 ---- — f——--- V E TANK FEE = $50.00 each TANK F t Tanks _ _ z $50.00 1986 1981 1988 1989 A (multiply i by fee for -- -- C each year applicable) — I -- — 4 L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) T t Tanks x $56.00 1986 1 1987 — 1988 1989 Y (enter aiount and year) -- — -- -- — ----F — $ C PERMANENT CLOSURE (Removal or Closure-in-place) — L— —— ---- --- 0 CLOSURE FEE = $90.00 each TANK t Tanks _� x $90.00 R TEMPORARY CLOSURE (Only allowed one time for up to two years) TEMPORARY CLOSURE FEE = $80.00 each TANK Y Tanks _—_ x $80.00 E P PLAN CHECK (Installation or Repair) — -- L ------ ----- ------- - -...-- — A N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ REPAIR R TANK REPAIR FEE = 1110.00 each TANK t Tanks_ x $110.00 f E -- - P — A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) I---- -- ---_ —. R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTIONSAMPLING INSPECTION (when applicable) (when applicable) (when applicable) FEE = $30.00/hr FEE = 435.00/hr -- FEE = 435_00/hr $ —— — TOTAL DUE f OFFICE USE ONLY SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT t --- ... —4 --- --._..--- _------------ -- -- --- ---------- l Lh C g]c��i.o hc�ao p�N