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k <br />sA ®AQU I N LOCAL HEALTH Li a STR I CT <br />r <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />FFACILITY/SITE NAME <br />FACILITY CONTACT NAME ^� <br />I /C� 0 Ci 10— <br />b a V `- <br />_ <br />L STREET ADDRESSko <br />1 <br />SITE PHONE 1 WITH AREA CODE <br />.237/ 5L kt)a <br />T.._ . _...�... _.. <br />Y CITY <br />wy <br />STATE 1IP CODE # of Tanks <br />-5 -dosI at Site <br />A APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />..._..____, ....,_____....._.__._ __...__.._____ _.. ___._..._........_....._...__ <br />.........._ <br />1986 1987 1988 1989 <br />___.__._..�......_..�__. .. <br />�_ _ _ .. _..._..._. _ .._.___...._.........._....._. <br />I MAILING ADDRESS <br />APPLICANT PHONE 1 WITH AREA CODE <br />f <br />L STATE SURCHARGE = $56.00 <br />T CITY <br />�2 <br />IP'CODE TYPE of APPLICATION <br />Ct.08URE. INSTALLATION. ETC. <br />JtL�- T <br />FACILITY FEE = $100.00 <br />each SITE ADDRESS per YEAR <br />A <br />N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION <br />TOTAL <br />A <br />C <br />T <br />�" <br />__ . __..__..._. ....... ____........__. ___._ .. _. __._ _ ...._. <br />1986 1987 1988 1983 <br />___ __C <br />------- <br />$ <br />E TANK FEE _ $50.00 each <br />TANK <br />F I Tanks x $50.00 <br />A(multipfy�l-by fee for <br />..._..____, ....,_____....._.__._ __...__.._____ _.. ___._..._........_....._...__ <br />.........._ <br />1986 1987 1988 1989 <br />___.__._..�......_..�__. .. <br />�_ _ _ .. _..._..._. _ .._.___...._.........._....._. <br />C each year applicable) <br />1-- <br />f <br />L STATE SURCHARGE = $56.00 <br />each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br />T f Tanks-- _ x $56.00 <br />Y L(,Ier eiount and year) <br />_ 1986 T <br />-- - --- --• <br />1987 <br />-- __ <br />_ 1988 <br />_ 1389 <br />__.. <br />._._...._ ._ _ <br />._...._ _ __._..._ <br />C9 0 <br />C PERMANENT CLOSURE (Removal or Closure-in-place)__......�.____...�... <br />A <br />N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION <br />$ <br />L...__..._...... <br />0 CLOSURE FEE = $90.00 each TANK <br />t Tanks <br />x $30.00 <br />$ <br />S <br />_ <br />U <br />R TEMPORARY CLOSURE (Only allowed one time for up <br />E _ <br />TEMPORARY CLOSURE FEE = $80.00 each TANK <br />to two years) <br />I Tanks <br />x $80.00 $ <br />P PLAN CHECK (Installation or Repair) <br />L <br />A <br />N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION <br />$ <br />REPAIR <br />R TANK REPAIR FEE - $110.00 each TANK...__�........____._._...,..�.._.����$ Tanksr ,•�x $110,00 <br />E ..__.._.............. ___........ __._............ <br />....... <br />.__._..._.._,......_.__.____.,_._. _.._ <br />P........ <br />A PIPING REPAIR,/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br />(when applicable) (when applicable) (when applicable) <br />........... _..__..._.... ___ _ .... __......__... _ _ ._ _. __. __.__.._.__.� _._........................ ..._ <br />FEE = $30.00/hr FEE $35.00/hr _ FEE = $35.00/hr $ <br />TOTAL DUE f �_ , 00 <br />OFFICE USE ONLY <br />.. .... l Is. I W, W.ITHIF,III,Ii1l�l►. ". !�I.1I M KIMW- 1EGi!�AI N inf$a3lif(!Gi N.III I;;aIil10 0MI9I HM MI.M "► <br />SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK, f/CASH RCVD BY DATE RECEIVED PERMIT t r <br />_.......... .... ... _.......... _.__...._.._....._.._..._ ..................... ........._.. _ ............. _ ._. _.._.........._......._......_ _ _._.. . <br />p�ryry''((qq��'' gyp/ ��mmpp'� ® �p pApfl,' �p� p py�p �ppppg�m ,gip p <br />�I'! !'111 op r li hI " �I t, Gli� i ll I!I{11;��I�J 't I ! "� i �Uflr'IA3��NUI��N�IumIN�NNlIAN6:N leftni A i . <br />[� <br />