Laserfiche WebLink
Qni% UAwu l w Lut;AL HEALTH D T —YR i C7 <br />ADERGROUND STORAGE TANK PROGRAM - FEE WORKSH_ <br />A <br />FACILITY/SITE NAME <br />FACILITY CONTACT NAME <br />I C <br />I <br />CLOSURE FEE = $90.00 each TANK <br />1986 <br />L <br />STREET ADDRES <br />SITE PHONE I WITH ARCA CODE <br />T <br />_ <br />R UNAUTHORIZED RELEASE EVALUATION <br />(when applicable) <br />Y <br />CITY 'nn <br />► QiVI <br />STAT <br />IIP CODE <br />'-'?,533 <br />It of Tanks <br />3 <br />E <br />l e C Ci�„' <br />F <br />A <br />C <br />I <br />6 <br />at Site <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />P <br />:�-e_r r <br />L <br />' So •� <br />1 <br />A <br />MAILING ADDRES �� g <br />%1'Q�S �' l� a( p om. S C <br />APPLICANT P(HOONE 1 WITH AREA CODE <br />O{ �' d7 Yl <br />N <br />T <br />CITY v <br />S oc <br />STAT <br />/IIP CODE <br />(..f 55),IT L(JIL..U.E <br />TYPE of <br />I BTALLw1lOHTC. <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 />1 Tanks x $80.00 <br />f <br />FEE = 130.00/hr <br />E <br />TANK FEE = $50.00 each TANK <br />F <br />A <br />C <br />I <br />1 Tanks_ 1 $50.00 <br />(:ultiply l by fee for <br />each year applicable) <br />1986 <br />1987 <br />1988 <br />1989 <br />$ �f <br />i <br />' So •� <br />$ C <br />J <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br />T <br />Y <br />1 Tanks_3_ x $56.00 <br />(enter mount and year) <br />1986 <br />1987 <br />1988 <br />1989 <br />C <br />L <br />PERMANENT CLOSURE (Reaoval or Closure -in-place) <br />LOC CODE <br />0 <br />S <br />CLOSURE FEE = $90.00 each TANK <br />t Tanks x $90.00 <br />------ <br />$ <br />U <br />I p11/i{'/ p 1I <br />i.i I ITITqiI''; ly�l�ll �I►IIXIII.MN' RIN IIIII II <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 />f <br />P <br />L <br />PLAN CHECK (Installation or Repair) 56)-- <br />LOC CODE <br />A <br />N <br />PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br />$ 3 Q�_— <br />REPAIR <br />COMP 1 <br />LOC CODE <br />R TANK REPAIR FEE = $110.00 each TANK <br />t Tanks x $110.00 <br />f <br />P <br />PERMIT 1 <br />I p11/i{'/ p 1I <br />i.i I ITITqiI''; ly�l�ll �I►IIXIII.MN' RIN IIIII II <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minisum one hour to be paid on plan subeittal) <br />I <br />R UNAUTHORIZED RELEASE EVALUATION <br />(when applicable) <br />CONSTRUCTION INSPECTION <br />(when applicable) <br />qllul� ��ellll�af,l <br />II?ar <br />SAMPLING INSPECTION <br />(when applicable) <br />FEE = 130.00/hr <br />FEE = $35.00/hr <br />FEE = $35.00/hr <br />$ <br />TOTAL DUE <br />$ �f <br />OFFICE USE ONLY <br />`05073 <br />SWEEPS 1 <br />COMP 1 <br />LOC CODE <br />DIST CODE <br />AMOUNT DUE AMOUNT RCVD <br />CHECK I/CASH <br />RCVD BY DATE RECEIVED <br />PERMIT 1 <br />I p11/i{'/ p 1I <br />i.i I ITITqiI''; ly�l�ll �I►IIXIII.MN' RIN IIIII II <br />�yWI �Ill�V�I4II1' I, I, u fl I1I III I <br />I -fill l <br />SO <br />VI l 0507 <br />P' <br />qllul� ��ellll�af,l <br />II?ar <br />Ilrl:I h�aGry.�ILo.n�.1'•I�n�:�,InId"l�Illnoru�I�Lu;1a17:N <br />