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onry v Wully LUGAL HEALTH DIST CT <br /> UN 2OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> I' <br /> L STREET ADDRESS SITE PHONE ! WITH AREA CODE <br /> I <br /> T <br /> Y CITY STAT TIP CODE 1 of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> C <br /> A <br /> N CITY STAT Z[P CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A— _ __ <br /> C 1986 1981 1988 1989 <br /> T <br /> I <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks x $50.00 1986 1987 1988 1989 <br /> A (multipfy-I by fee for <br /> C each year applicable) � 1 0� � OCA $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T ! Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiiHt and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) .1 t4 v g0 <br /> L <br /> O CLOSURE FEE = $90.00 each TANK 1 Tanks x fx9QE6 a f — <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) Qt PL <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <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 f <br /> E <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour 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 = $35.00/hr FEE = $35.00/hr $ <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> AI X <br /> II In I. I II <br /> SWEEPS ! COMP 1 LOC CODE DISI CODE AMOUNT DUE AMOUNT RCI CHECK !/CASH KCVO BY DATE RECEIVED PERMIT ! <br /> I!I!I!�D!Ir u91N' II D J4 ' ' : ' <br />