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:,•,�C, A4dU1,,4 LUt_:AL HIEALTH D 2ICT <br /> RGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME ` <br /> A FACILITY COHTACT`NAME <br /> /j_ <br /> it <br /> L STREET ADDRESS <br /> 1 PRONE I WITH ^ACA coos <br /> ao�7 /t/. P� z , SITE C a o e" <br /> Y CITY ! STAT IIP CODE It of Tanks <br /> at Site , <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I MAILING DDRESS APPLICANT PHONE I <br /> 5,) ru MITA AA[A COO( <br /> A clTr ,vim S �- <br /> Ti �.(y1 G jy� IP CODE PPLICATION <br /> `1� CLOAi7A ALLAT=OM, CTC. -E� <br /> FACILITY FEE = 1100,00 each SITE ADDRESS per YEAR <br /> ATOTAL <br /> T 1986 1987 1988 1989 <br /> I r / <br /> V <br /> E TANK FEE = 150.00 each TANK <br /> F I Tanks z 150.00 1986 1987 <br /> A (multiply 1'Dy tee for 1988 1989 <br /> C each year applicable) <br /> L SLATE SURCHARGE _ $56.00 each TANK (see CA HEALTH i SAFETY CODE Set 2528] (Orapplicability) <br /> n C <br /> 56 <br /> l <br /> T I Tanks z 156.)0 1986 <br /> Y (enter Nalit and year) 1987 1908 1989 <br /> C PERMANENT CLOSURE (P,emoval or C <br /> L losure-in-place) <br /> 0 CLOSURE FEE _ h T <br /> 190,00 each 5 1 Tanks <br /> U ------ <br /> x $90.40 1 <br /> R TEMPORARY CLOSURE (Only <br /> E allowed one time for up to two years) <br /> IEKPORARY CLOSURE FEE = $80.00 each TANK <br /> # Tanks _ x fB0,00 1 <br /> P PIAN 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 = 11!0.00 each TANK <br /> E t Tants - - x 1110.00 <br /> A PIPING REPAIRICLOSURE/REMOVAL (Fees are per hour, :inisum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (when applicable) . (when applicable) SAMPLING INSPECTION <br /> (when applica <br /> FEE = $34.00/hr FEE ble) <br /> FEE = hr 1 <br /> 4fF1tF USE ONLY a --d 3 —P� .— /So TOTAL DUE $ (� <br /> /�.l pe,L. .a _ <br /> S Tim g'.Fli <br /> SWEEPI COMP # LOC C <br /> ODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASK RCVD BY DAIE RECEIVED p <br /> _le <br />