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o n T14 . wulw Luc:AL HtALTH DIST " Cl- Q I( <br /> UNOV-6ROUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> L STREET ADDRESS SITE PHONE t WITH AREA CODE <br /> T \s n <br /> Y CITY STAT P CODE f of Tanks <br /> v L ,c. C f� 9 5dOJ at Site \fIIC � <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE t WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLUOUREr rNETALLATION. ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A _ TOTAL <br /> -- - _ <br /> C 1986 1981 1988 1989 <br /> T <br /> I --V - <br /> E TANK FEE = $50.00 each TANK <br /> F I{ Tanks _- _ x $50.00 1986 1981 1988 1989 <br /> A (multiply ( by fee for <br /> I each year applicable) <br /> �)o f <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25281 for applicability) <br /> T t Tanks _ x $56.00 1986 1981 19=1989 <br /> Y (enter amount and year) -- _ <br /> FPERMANENT CLOSURE (Removal 6r Closure-in-place) <br /> FEE = $90.00 each TANK t Tanksx $90.00 RY CLOSURE (Only allowed one time for up to two years) RECEIVED <br /> Y CLOSURE FEE = $80.00 each TANK <br /> � t <br /> P PLAN CHECK (Installation or Repair) <br /> L NVIRONMFPJTAI<HFA17H <br /> A PERMIT/SERVICES <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK t Tanks x (110.00 $ <br /> E ------ {� — <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour7hour <br /> to be paid on plan submittal) <br /> I — <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.00/hr FEE FEE _ $35.00/hr f <br /> TOTAL DUE <br /> OFFICE USE ONLY - <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT $ <br /> I,I I WWY� IIIrv.q.11 p� � 1 ", �q i�„ II YIWIIWIYW I II I'IIIII'II Ii �'/� :WwIUWWYI���'IiItlWWW� II'III'I�III''III <br /> 1 YWWWWYI mIW WH' .� py�yWllWtlllmW��m�wmm �!. <br />