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Q"s% -,'tAuu l Iv LOCAL HEALTH DIS—'?ICT <br /> U`"%RGROUND STORAGE TANK PROGRAM - FEE WORKSHEET``"'\ <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C ` S (L <br /> I <br /> L STREET ADDRESS SITE PHONE # WITH AREA COOK <br /> I � S rl <br /> T ` <br /> Y CITY STAT fiP CODE # of Tanks <br /> 9 Sapp at Site 1 Rr\ #3 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH ARK^ CODE <br /> C <br /> A <br /> N CITY STAT ZIP CODETYPE of APPLICATION <br /> T CLOSURE, INSTALLATION. ETC. <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> V $--�-- <br /> E TANK FEE _ $50.00 each TANK <br /> F # Tanksf _ x $50.00 1986 1987 1988 1989 <br /> A (multipry-IF by fee for <br /> I each year applicable) O 5 S O ; <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH t SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T # Tanks 1 x $56.00 1986 1987 1988 1989 <br /> Y (enter mount and year) / <br /> �o $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK # Tanksx $90.00 <br /> S __ <br /> U <br /> Ir— <br /> RMPRARY CLOSURE (Only alloyed one time for up to two years) RECEIVED <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK <br /> P PLAN CHECK (Installation or Repair) N <br /> L114 <br /> A PERMIT/SERVICES <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R TANK REPAIR FEE = $110.00 each TANK # Tanks x $110.00 f � <br /> E <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 COD$ DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT # <br /> 42 > 2010Zo ,� Co�r�S J3 E <br /> n <br />