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r7tl1I,1 -, UAttu 1 w LUGAL HEALTH D I c"'R I CT <br />ERGROUND STORAGE TANK PROGRAM -TEE WORKSHE. <br />r <br />FACILITY/SITE NAME <br />FACILITY CONTACT NAME <br />I <br />CLOSURE FEE = $90.00 each TANK <br />1986 <br />L <br />STREET ADORES <br />fie. ��� <br />SITE PHONE 1 WITH AREA COO[ <br />T <br />. i3 r, S m� <br />R UNAUTHORIZED RELEASE EVALUATION <br />(when applicable) <br />Y <br />CITU I <br />STAT <br />IIP CODE <br />1 of Tanks <br />3 <br />E <br />a,*, f C CVJam" <br />F <br />A <br />C <br />I— <br />1 Tanks_ x $50.00 <br />(multiply 1 by fee for <br />each year applicable) <br />— <br />at Site <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />P <br />urer r <br />O o rc_ <br />/50— <br />-I <br />MAILING ADDRES , <br />I/� -�f^_ <br />APP L CANT PHONE 1 WITH AREA COO[ <br />A <br />J ^ Q <br />W I o 1 O `�+ c <br />O 1 U r <br />N <br />T <br />CITU (� <br />S O�7 <br />STAT <br />TIP CODE <br />056D Lf <br />TYPE of <br />CLOG At I�TALLAiIONTC. <br />A <br />FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br />-- <br />TOTAL <br />C <br />T <br />1 <br />V <br />CLOSURE FEE = $90.00 each TANK <br />1986 <br />1987 <br />1988 <br />1989 <br />R <br />E <br />_ <br />R UNAUTHORIZED RELEASE EVALUATION <br />(when applicable) <br />CONSTRUCTION INSPECTION <br />(when applicable) <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />/00_ <br />1 <br />$ <br />E <br />TANK FEE = $50.00 each TANK <br />F <br />A <br />C <br />I— <br />1 Tanks_ x $50.00 <br />(multiply 1 by fee for <br />each year applicable) <br />— <br />1986 <br />1981 <br />1988 <br />1989 <br />` <br />/50— <br />$ i .S d <br />L <br />STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Set 25287 for applicability) <br />T <br />Y <br />1 Tanks_3_ x 156.00 <br />(enter mount and year) <br />1986 <br />1987 <br />1988 <br />1909 <br />C <br />L <br />PERMANENT CLOSURE (Removal or Closure -in-place) <br />-- <br />0 <br />S-- <br />CLOSURE FEE = $90.00 each TANK <br />1 Tanks x $90.00 <br />------ <br />1 <br />U <br />R <br />E <br />TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />R UNAUTHORIZED RELEASE EVALUATION <br />(when applicable) <br />CONSTRUCTION INSPECTION <br />(when applicable) <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />1 Tanks x $80.00 <br />1 <br />P <br />L <br />PLAN CHECK (Installation or Repair) 56)-- <br />3 D `' <br />A <br />N <br />PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION <br />$ 3 Q`— <br />REPAIR <br />R TANK REPAIR FEE = 1110.00 each TANK <br />t Tanks x 1110.00 <br />f <br />P <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 <br />(when applicable) <br />CONSTRUCTION INSPECTION <br />(when applicable) <br />SAMPLING INSPECTION <br />(when applicable) <br />FEE = 130.00/hr <br />FEE = 135.00/hr <br />FEE = 135.00/hr <br />$ <br />TOTAL DUE <br />1 It <br />off /ct U51 ONLY C4tK "- OSD 73 <br />SWWEEEPSu1 COMP{�1 LOCO COODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVEDJ PERMIT 1 <br />�110ir�i pt niwp.. �aAI�naisiII 11 tllllll,ltll tlllw{IIwl,13,1f , .,...�, „ `f.,, ..,,,....� '.Y. _ . _7��0 (Ff <br />t✓ <br />