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.r.,w U .e idU l ev LuCAL HEALTH D I S . I CY <br />ROUND STORAGE TANK PROGRAM - FEE NORKSHEE <br />A FACILITY/SITE NAME FACILITY CONTACT NAME <br />oe <br />L STREET ADDRESS <br />t SITE PHONE # WITH AREA CODE <br />� <br />Y CITY _ # l <br />STA ZIP CODE of nks <br />at Site <br />A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br />P <br />L / <br />I MAILING ADDRESS APPLICANT PHONE # WITH AREA COOK <br />C <br />e I CITY STAT IIP CODE TYPE of APP <br />G^ CLOBUREs ALLATIOH. TC. <br />FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br />A TOTAL <br />1986 19a7 1988 19A9 �— <br />I <br />I <br />v <br />$ <br />E TANK FEE = $50.00 each TANK <br />SWEEPS # <br />COMP # <br />LDC CODE DIST CODE <br />AMOUNT DUE <br />AMOUNT RCVD <br />CHECK WASH RCVD BY <br />F # Tanks x $50.00 1986 1987 1988 1989 <br />A (sultipIy-#-by fee for <br />C each year applicable)$ <br />6111rir!t��Ii1Glp";' , <br />� <br />i <br />fill M �P Pr.wuNplilgNrp�µ <br />I <br />ry <br />9 li nm I i n ix m IM „n�, <br />�IIIII.«�uii7u,iiHtlinN,r41, <br />L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH # SAFETY CODE Sec 25287 for applicabil'ty) <br />I <br />T # Tanks x $56.00 1986 1987 <br />Y (enter mount and year) <br />1988 <br />1989 <br />C PERMANENT CLOSURE (Resoval or CIosure-in-place) <br />L <br />0 CLOSURE FEE -- $90.00 each TANK <br />S <br /># Tanks <br />------ x $90.00 <br />$ <br />U <br />R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br />E <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br /># Tanks <br />x $80.00 <br />$ <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 IANK REPAIR FEE = $110.00 each TANK <br /># Tanks <br />_ x $110.00 <br />$ <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, sinisus one <br />I <br />hour to be <br />paid on plan subsittal) <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br />(when applicable) (when <br />SAMPLING INSPECTION <br />applicable) <br />(when <br />applicable) <br />FEE FEE = $35.00/11ir <br />FEE <br />TOTAL DUE <br />OffZCE USE ONLY <br />I <br />II( '! nr I' I' I i rn. ��rq,' <br />SWEEPS # <br />COMP # <br />LDC CODE DIST CODE <br />AMOUNT DUE <br />AMOUNT RCVD <br />CHECK WASH RCVD BY <br />DATE RECEIVED PERMIT # <br />6111rir!t��Ii1Glp";' , <br />� <br />fill M �P Pr.wuNplilgNrp�µ <br />I <br />ry <br />9 li nm I i n ix m IM „n�, <br />�IIIII.«�uii7u,iiHtlinN,r41, <br />