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'? Q"N JUAmU1rV~LucAL HtALTM DiS1K1Cl <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY/SITE NAME FACILITY CONTACT NAME <br /> 4 O/ <br /> STREET AODRES SITE PHONE 1 v h Area Code) <br /> oZ 6 6 d <br /> CITY r STATE IIP CODE 1 of TANK'S <br /> S.?U at Site <br />(APPLICANT/BILLING NAME APPLI T CON ACT NAME <br /> ' a <br /> iMAILING ADDRESS APPLICANT PHONE f (with Area Code) <br /> CITY STATE IIP CODE TyP PLICATION <br /> C,a (C osure, stallation, etc.) <br />;FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> 1986 1987 1988 1989 <br /> fE'AYMENT '' <br /> TANK FEE _ $50.00 each TANK <br /> I Tanks r f50.00 1986 1987 1988 1989 �q b <br /> (multiply f by lee for <br /> each year applicable) ENV <br /> STATE SURCHARGE = $56.00 each TANK (see CA HEALTH f SAFETY LODE Sec 25287 forapplicability) PE <br /> RMfT/SERVIC i <br /> 1 Tanks__ __ 1 $56.00 1986 1987 1988 1989 <br /> (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> CLOSURE FEE = $90.00 each TANK t links,/4- $90.00 f <br /> TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks z $80.00 t <br /> PLAN CHECK (Installation or Repair) <br /> PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> TANK REPAIR FEE _ $110.00 each TANK 1 Tanks 1 $110.00 f <br /> i <br /> PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (vhen applicable) INSPECTION INSPECTION �i' <br /> FEE = $30.00/hr FEE = $35.00/hr FEE = $35.00/hr f <br /> TOTAL DOE $ <br /> OFFICE USE ONLY <br /> SWEEPS t COMP / LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> �'dhau4Nui Jl'- ":4..IMMlMtWXNAY .,.. .. <br />