Laserfiche WebLink
.+r+1% AWU114 Lut:AL HEALTH DI RICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> f FACILITY/S11E NAME FACILITY CONTACT NAME <br /> A <br /> II <br /> L STREET ADDRESS SITE PHONE 1 YITH ARCA CODE <br /> Y CITY STAT 11P CODE 1 of Tanks <br /> r C-�l� at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P r c7 l"�`' FCS++" <br /> 1 MAILING ADDRESS <br /> C APPLICANT PHONE 1 WITH AREA CODE <br /> A <br /> rr CITY <br /> I STA1 IIP CODE TYPE of APPLICATION <br /> CLOtlUAl, IM�YwLlw110M, ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> A'- TOTAL <br /> C 19BG 1907 1980 1989 <br /> I <br /> l <br /> V $ <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks _ x $50.00 1906 1987 1900 1989 <br /> A (multiply l-by fee for <br /> C each year applicable) <br /> I $ <br /> L STATE SURCHARGE = $56,00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> T I Tanks x $56.00 1986 1907 1980 1909 <br /> Y (enter Mount and year) <br /> $ <br /> FIA LOSURE (Removal or Closure-in-place) <br /> = $90,00 each TANK1 tanks x $90.00 OSURE (Only allowed one time for up to two years) <br /> OSURE FEE = $00.00 each TANK 1 Tanks x $80.00 <br /> t <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK IEE = $30,00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R TANK REPAIR FEE : $110.00 each TANK <br /> E 1 Tanks ----- x $110.00 $ <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (fees are per hour, minium one hour to be paid on plan submittal) <br /> t <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING <br /> (when applicable) (when applicable) able)INSPECTION <br /> 11 PP (when applicable) <br /> FEE = $00.00/hr FEE IEC = $35,00/hr $ <br /> J <br /> TOTAL DUE $ <br /> OffltE USF OrY(r <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD HECK /CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> ;0 lxr' ^ c— <br /> I�ufl� I „L.1— � , <br /> i IVdUIIP�;'VI9111L9111�1i11'IOIIVIpl114nlfll�" <br />