Laserfiche WebLink
.Toms% UAwU 1 ev LUL;AL HEALTH D1'R T Cl' <br />DERGROUND STORAGE T,Nr PQnro6" _ rrr unavc <br />A �°ACILITY/SITE NAME <br />r►c�c` <br />1 STREET ADDRESS <br />T �� <br />Y CITY STA <br />A <br />PAPPLICANT/BILLING NAME <br />HAILING ADDRESS <br />r s' <br />`r- M �W_ <br />FACILITY CONTACT NAME <br />SITE ONE 1 NIT" ARCA cool <br />ZIP CODE 1 of Tanks <br />lat Site <br />FW1 <br />APPLICANT CONTACT NAME <br />APPLICANT PHONE 1 MIT" ARCA coal <br />DE LlYPE of APPLICATION <br />LOGURE, IN®TALLATION. ETC. <br />A <br />M I L11Y FEE = 1100.00 each SITE ADDRESS per YEAR <br />TOTAL <br />C 1986 1987 <br />T <br />E <br />1988 <br />1989 <br />I <br />V <br />E TANK FEE _ $50.00 each TANK <br />F 1 Tanksx $50.00 1986 1981 <br />A (multip y I -by fee for <br />1988 <br />1989 <br />C each year applicable) <br />L <br />$ �- <br />1 STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br />T 1 Tanks x $56.00 1986 1987 <br />Y (enter iiount and year) <br />1988 <br />1989 p <br />$ <br />C PERMANENT CLOSURE (Removal or Closure -in-place) <br />L <br />0 CLOSURE FEE _ $90.00 each TANK <br />S <br />1 Tanks_ <br />z f90.00 <br />f <br />U <br />R TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br />E <br />TEMPORARY CLOSURE FEE = $00.00 each TANK <br />1 Tanks <br />$80.00 <br />x <br />P PLAN CHECK (Installation or Repair) <br />L <br />A <br />N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION <br />$ <br />REPAIR <br />R TANK REPAIR FEE = $110.00 each TANK <br />E <br />1 Tanks <br />1 $110.00 <br />P <br />_ <br />$ <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one <br />I <br />hour to be <br />paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br />(when applicable) <br />SAMPLING INSPECTION <br />(when applicable) <br />(when <br />applicable) <br />FEE = 130.00/hr FEE _ $35.00/hrl <br />FEE = <br />135.00/hr f <br />TOTAL DUE f �� <br />OFFICE USE ONLY <br />-- <br />mmmmul <br />1 <br />SWEEPS 1 COMP 1 LOC CODE DIST CODE1 AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br />L i i .iN71r %61111111NIIl%I MIIbpNll�llir!IIdIIRiItlNNlinm11 xnm�.�m...�N .� f'_,,,, ,....,.,......_ / I <br />