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w <br /> or+sw j UAwu 1 w LUCAL HEALTH DISTRICT <br /> U*ROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> (A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C + � ¢ bvk,lr 6S <br /> I <br /> L STREET AD RES SITE�PHONE #IWITH AR A CODE <br /> Y CITY STATE IIP CODE # of Tanks <br /> pYc l�� (A ?S"�3/1 at Site / <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT AME <br /> P ) <br /> c MAILIN67IDDRESS APPL�ANT P NE # WI AREA CODE <br /> A- G9 <br /> N CITY n STATE IIP CODE TYPE of APPLICATION <br /> T .{-1 CLOSURE, INSTALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> T 1986 1987 1988 1989 <br /> V -- <br /> E TANK FEE = $50.00 each TANK <br /> F # Tanks _ x $50.00 1986 1981 � 1988 1989 <br /> A (aultipTy-E by fee for ----— ------ __ _ <br /> C each year applicable) _ $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> I -- ----– _ ._ <br /> T # Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter i"sount and year) _.. <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L -- - <br /> 0 CLOSURE FEE = $90.00 each TANK # Tanks x $90.00 $ <br /> U----- - <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> /�� - <br /> L <br /> A - <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSIONit Ic <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK # Tanks x sll@ $ <br /> F <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid o1 �Qi V1C S <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 <br /> OFFICE USE ONLY <br /> 7�S�WffPS COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK # SN RCVD BY DATE RECEIVED PERMIT # <br /> i • <br />