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SAN TOAGIUIN LOCAL HEALTH DI RIOT <br /> - <br /> 6RGROUND STORAGE TANK PROGRAM - FEE WORKS <br /> ;j <br /> FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C—Oldlelk, S1010 IcK gr4aIA <br /> I <br /> L STREET ADDRESS SITE PHONE # WITH ARCA CODE <br /> T <br /> Y CITYSTAT ZIP CODE # of Tanks <br /> L od( at Site <br /> AP APPLICANT/BILLING NAMEAPPLICANT CONTACT NAME <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH ARCA CODE <br /> C 405— a <br /> A— <br /> NT <br /> CITY STATE ZIP CODE TYPE of APPLICATION <br /> C, gqC CLOSURE, INSTALLATION, CTC. 5, �/� l� <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A. <br /> T 1986 1987 1988 1989 <br /> I f <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F # Tanks x $50.00 _ 1986 1987 1988 1989 <br /> A (multiply i-by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T # Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter aiou6t and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK # Tanks x $90.00 $ <br /> S - - <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 # Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) 1 /x/ /scr z, X161 s 3) <br /> L (67 <br /> N PLAN CHECK FEE = $30.00 each SUBMIS ION/RESUBMISSION $ <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK # Tanks x $110.00 f <br /> P <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) (when applicable) (when applicable) <br /> FEE = $30.00/hr FEE = $35.00/hr FEE = $35.00/hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> SWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT # <br />