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. : ns% .a uAvtu l Iv LuVHL. HEALTH DlAf&RICT <br /> RGROUND STORAGE TANK PROGRAM - FEE NORKSH <br /> FrAMITY/SITE NAME <br /> A FACILITY CONTACT NAME <br /> trC <br /> I <br /> L STREET ADDRESS SITE PHONE 1 MIT" ARCA coot <br /> 3 <br /> T <br /> Y CITY STAT ZIP CODE Elof Tanks <br /> Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> 1 MAILING ADDRESS <br /> C APPLICANT PHONE i MIT" AR[A cooc <br /> A <br /> T CITY STAT ZIP CODE TYPE of <br /> GLOBYRE I"iTAL6wT10 tTC. <br /> A FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> C <br /> T 1986 1987 1988 1989 p�® <br /> I <br /> V E1 <br /> E TANK FEE -- $50.00 each TANK <br /> f 1 Tanks x 150.00 1986 1987 1988 1989 p <br /> A (multipfy-"("by fee for <br /> C each year applicable) �- 1 <br /> I 0 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH $ SAFETY CODE Set 25287 for applicability) <br /> I <br /> T 1 Tanks x 156.00 1986 1987 1988 1909 <br /> Y (enter i®®unt and year) <br /> (� 1 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = 190.00 each TANK <br /> S 1 tanks z 190.00 1 <br /> u - <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x 180.00 1 <br /> (P PLAN CH (Installation r Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK <br /> E 1 Tanks _ x 1110.00 1 <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr FEE a $35.00/hr FEE = 135.00/hr <br /> $ <br /> OFFICE USE OILY TOTAL DU!"! <br /> i am mum <br /> 7SWEEPS COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD HEC /CASH KCVO BY DATE RECEIVED PERMIT 1 <br /> 31 16 r 35 <br /> .4 <br />