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uns% r uAwU 1 Tv LuL;AL HEALTH D I 'R I CT ORGROUND STORAGE TANK PROGRAM - FEE NORKSH i 6- I <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C <br /> f <br /> L STREET WRESS C_ SITE PHONE 1 WITH AREA CODE <br /> T U <br /> Y CITY STAT IIP CODETat <br /> of Tanks <br /> � ` a Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE 1 "TTN AREA CODE <br /> A <br /> N <br /> CITY STAT IIP CODE ITYPE of APPLICATION <br /> 6L0®URE, TN®TALLATION. ETC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> V f <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks x $50.00 1986 1987 1988 1989 <br /> A (multipl'y I"by fee for <br /> C each year applicable) $ <br /> t <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> T 1 Tan <br /> Y (enterks mount x an156.00 1986 1987 1988 1989 �' d <br /> d year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L '9l <br /> 0 CLOSURE FEE = $90.00 each TANK 1�Tanksf90.00 $ /CF q` <br /> U <br /> RTEMPORARY CLOSURE (Only allowed 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 = 130.00 each SUBMISSION/RESUBMISSION <br /> f <br /> REPAIR <br /> R LANK REPAIR FEE = $110.00 each TANK 1 Tanks__ x 1110.00 1 <br /> Po L <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (vhen applicable) _ (when applicable) <br /> FEE = f3@.00/hr FEE = 135.00/hr FEE = $35.00/hr <br /> 1 <br /> s °p- <br /> OFFICE USE ONLY TOTAL DUE <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK i/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> ,� <br />