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SAN&AGUIN LOCAL HEALTH DORICT <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />IF FACILITY/SITE NAME <br />TOTAL <br />FACILITY CONTACT NAME <br />1A <br />C <br />1 ---L I <br />- - - — — -------- <br />CLOSURE FEE = $10.00 each TANK # Tanks x $90.00 <br />#Tanks z $110.00 <br />T- <br />L STREET ADDRESS <br />U <br />SITE PHONE # "T" ARKA c006 <br />C <br />1986 <br />1987 <br />T <br />- <br />H <br />Y CITY <br />STATE .ZIP CODE of Tanks <br />one hour to be paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION <br />It <br />at Site <br />A APPLICANT/BILLING NAME <br />- <br />APPLICANT CONTACT <br />P <br />(when applicable) <br />E TANK FEE = $50.00 each TANK <br />P <br />L <br />C each year applicable) $ 15-0,00 <br />1 <br />L STATE SURCHARGE = 456.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br />I MAILING ADDRESS <br />1986 <br />APPLICANT PHONE I <br />r. <br />------ <br />N CITY <br />T <br />J ENVIRONIVIEWjj1:A1 TLF <br />STAT DE .TYPE of APPLICATN' AI <br />CLOOURE, MTALLATION, M. <br />A FACILITY FEE z $100.00 each SITE ADDRESS per YEAR <br />. ..... ..... <br />TOTAL <br />0 <br />- - - — — -------- <br />CLOSURE FEE = $10.00 each TANK # Tanks x $90.00 <br />#Tanks z $110.00 <br />E <br />U <br />- <br />C <br />1986 <br />1987 <br />1988 <br />1989 <br />H <br />E <br />T <br />one hour to be paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION <br />CONSTRUCTION INSPECTION <br />- <br />(when applicable) <br />I <br />V <br />(when applicable) <br />E TANK FEE = $50.00 each TANK <br />F I Tanks -3._._Y <br />i50.00 W YMyw 1986 1987 1988 1389 jp <br />A (multiply"I-by fee for <br />C each year applicable) $ 15-0,00 <br />1 <br />L STATE SURCHARGE = 456.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br />T I Tanks -3 x $56.00 <br />Y (enter iiKht and year) <br />1986 <br />1987 <br />1988 <br />1989 <br />4f 0 <br />C <br />L— <br />PERMANENT CLOSURE (Removal or Closure -in-place) <br />0 <br />- - - — — -------- <br />CLOSURE FEE = $10.00 each TANK # Tanks x $90.00 <br />#Tanks z $110.00 <br />E <br />U <br />- <br />P - <br />R <br />TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />E <br />TEMPORARY CLOSURE FEE : $80.00 each TANK I Tanks x $80.00 <br />one hour to be paid on plan submittal) <br />P PLAN CHECK (installation or Repair) <br />L------ <br />A <br />N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br />REPAIR <br />P TANK REPAIR FEE = $110.00 each <br />TANK <br />#Tanks z $110.00 <br />E <br />P - <br />A PIPING REPAIR/CLOSURE/REMOVAL <br />(Fees are per hour, minimum <br />one hour to be paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION <br />CONSTRUCTION INSPECTION <br />SAMPLING INSPECTION <br />(when applicable) <br />(when applicable) <br />(when applicable) <br />FEE <br />FEE = $35.00/hr <br />FEE hr <br />.... . ..... <br />TOTAL DUE $ <br />OFFICE USE ONLY <br />P <br />. . . . . . . . . . . <br />SWEEPS COMP I LOC C00E GIST CODE AM0UNT 0 U E AMOUNT RC VD <br />... .. .. ... <br />,J/CAI�...j DATE RECEIVED PERMIT I <br />—77 — <br />l9e) I / dS <br />