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r <br /> - %2nN .JUAWUI'AWLUCAL HtALTH D1S11<icl <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />'ACUITY/SITE NAME FACILITY CONTACT NAME <br /> r? f C V <br />;TREET AODRES SITE PHONE 1 LwLth Area Code) <br /> g6 � p <br />:ITY STATE IIP CODE 1 of TANK'S <br /> l S'�p at Site <br /> APPLICANT/BILLING NAME APPLI T CON ACT NAME <br /> ZV—.Q L Z�Z Y/ � _.,Z ri L4 a <br /> 1AILING ADDRESS APPLICANT PHONE 1 (with Area Code) I ' <br /> CITY STATE ZIP CODEtl'�'� <br /> ICATION <br /> o�ure, stallation, etc.) <br /> I <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> 1986 1981 1988 1989 <br /> s PAYMENT <br /> TANK FEE _ $50.00 each TANK i <br /> 1 Tanks x $50.00 1986 1981 1988 1989 JAN G 1q"3 <br /> ti tiply-;-by fee for <br /> each year applicable) ENV <br /> STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25281 for applicability) PERMlT�SFRVIC <br /> ES 1 Tanks x $56.00 1986 1981 1988 1989 <br />(enter aaount and year) <br /> $ <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> CLOSURE FEE _ $90.00 each TANK 1 Tanks x $90.00 s <br /> TEMPORARY CLOSURE (Only allowed one time for up to two years) r <br /> TEMPORARY CLOSURE rEE _ $80.00 each TANK 1 Tanks x $80.00 $ I; <br /> PLAN CHECK (Installation or Repair) <br /> PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> I <br /> REPAIR <br /> TANK REPAIR FEE _ $110.00 each TANK 1 Tanks..... x $110.00 $ <br /> PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> j(when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE = $35.00/hr $ <br /> $ <br /> i <br /> OFFICE USE ONLY TOTAL DUE <br /> SWEEPS 1 COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK UCASH RCVD BY DATE RECEIVED PERMIT 1 <br />