Laserfiche WebLink
rj"$% UAWU 1 Tv LUCAL HEALTH D�.,�TR I CT <br /> UNDERGROUND ARAAE°�(N� PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE N//AME FACILITY CONTACT NAME <br /> I dA«(�7ri <br /> I C�? <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA COOK <br /> I -23 <br /> T <br /> Y CITY STAT ZIP CODE t of Tanks <br /> 3. .3r at Site <br /> A APPLICANT/BILLING NAME APP�L,IICANT CONTACT NAME <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> N CITY / STAT ZIP CODE TYPE of APPLICATION <br /> T L CLODURE, INSTALLATION. ETC.AQ fmc <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A- <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 $ <br /> Vr <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanksx $50.00 1986 1981 1988 1989 <br /> A (sultipri-I_by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH It SAFETY CODE Sec 25287 for applicability) <br /> • I <br /> T 1 Tanks x 156.00 1986 1987 1988 1989 <br /> Y (enter Siount and year) <br /> t <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> S 1 Tanks x $90.00 f <br /> - ---- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK t Tanks x $80.00 S <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK t Tanks x $110.00 f <br /> E ----- <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 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 1715 <br /> OFFICE USE OILY <br /> mmHg,Iffilm.,00=1150 <br /> SWEEPS 1 COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK /CASH RCVD BY DATE RECEIVED PERMIT t <br /> �3s D° <br /> .�!71M�u;rrly�y !��ryn„nI!II�G•! : Qw� 9 I I i. ! ! ! ���1�i�m�I'��fl!����NIII''!!�����yy�q!������q�n��!!��!n N!tl1 I!�ryrygg!n'!pp� !! III q I ! �yl � n! ! I i! i I. i I_h II ' i I•yII „„y i' � m i!q! <br /> ��3i�IRE�� WYWYu6YlYIWIWIWWIUitlIYItlW''y!In�IU,I u !J IdN�'1•dli!Ih ��! I !'I II I!I! !p II !x!!II!tll!'!M4I!I,'";.III,IM!II. ��I�' d L�H�I�Ii,�ItlnilYll��d•i��.liJihu�!ull;�' <br />