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SIU 1 ev LUCAL HEALTH D I S40I CT <br /> ' s U GGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> AF FACILITY/SITE NAME FACILITY CONTACT NAME <br /> I hT. G /11h1i�fj 1-{p t O = MA"Tt;e---A K�oU7*Ab<t'3 <br /> STREET ADDRESS SIE PH01F 1 wITN AREA coca <br /> T l'1 <br /> Y CITY STAT IIPCODE i of Tanks <br /> � TT�G,A a1�3 Lr lat Site <br /> A APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> P <br /> L 15T. <br /> I MAILING ADDRESS PPLIC T PHONE 1 ITN AREA CODE <br /> 160 N . (AL4 <br /> N CITY �ry�.1�r' STAT ZIP CODE TYPE of APPLICATION <br /> TG's`d� CL08UREv INSTALLATION. ETC. <br /> FACILITY FEE = 4100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C 1986 1981 1988 1989 <br /> T <br /> I <br /> V f �� O <br /> E TANK FEE = 150.00 each TANK <br /> F f Tanks ,� x $50.00 1986 1981 1988 1989 <br /> A (wltipli 1-by fee for <br /> C each year applicable) $ �D <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 4 SAFETY CODE Set 25287 for applicability) <br /> I <br /> T I Tanks_ x $56.00 1986 1987 1988 1989 <br /> Y (enter aaount and year) _. <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks x $90.00 $ <br /> S <br /> U - --- <br /> ::::d <br /> R TEMPORARY CLOSURE (Only a'lowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 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 1 �� <br /> REPAIR <br /> R TANK REPAIR FEE = 4110.00 each TANK 1 Tanks $ <br /> E _ x 4110.00 <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan subEittal) <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 = S35.00/hr $ <br /> TOTAL DUE f 'L7 3�, 06 <br /> OFFICE USE ONLY <br /> N.,I i I I M.N!IIIt!ri' <br /> SWEEPS 1 M 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK {/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 'td / <br /> n n !1 P,!iA n�1pRpf? 7 <br /> a ! <br /> ! m v <br /> m +� <br />