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SAN TnAt�"'.; "'AN L0C11L
<br />HEALTH DIS-I'R
<br />U11DEk" J STO�AGi: TANK PROGRAMS - FEE WORKSHEET
<br />F'.e:L;,rY/s1TE TIAISEI
<br />................
<br />� ,,,,.m.,� �;;, ,, , ,,, � n,�,,,
<br />---__.._----_-------------__---
<br />FACiI.IT'i COHTIM NIHIL- _...I
<br />�H'EEPS CC.1F LOC )'.ODE
<br />DIST COC-
<br />A�,Oi1NT DUE
<br />A�t(IUNT f:C.Y0 i'ilI.�;K,
<br />k/r:A H
<br />RC;'D DY
<br />DATE RECEI')ED
<br />_-�-fa�
<br />32a._
<br />i1. STf.EET ADDRESS
<br />....._...�
<br />........._....�
<br />SITE PHONE R 111111 earn cooF
<br />iIC[Tl'
<br />�.?` ri I . ��, .
<br />STATE
<br />.... .. _ - --
<br />BF ]ME t f T
<br />oan1:s
<br />Site
<br />.................. ..............................
<br />........
<br />.... .__........_... ............ ......_.
<br />at
<br />...... ..... _ ..... .......... .............
<br />A APPLICANT/BILLING !CAME
<br />F
<br />_... .._.....__.._..._.........._.:. --- ------
<br />APPLICANT CONTACT NAVE
<br />Wit_._.._. __ . rJ
<br />..
<br />` r, r
<br />I I I1A1' IN6, AD�.EJ-S
<br />) WTTH AREA CO ur
<br />APPLICANT F11 _
<br />f_...`�u.�l__...�a.....�.......
<br />,.� � ) / Irk
<br />N CITY
<br />''^''r�
<br />{ ;TATE
<br />ZIP CODE
<br />TYPE of APPLICATION
<br />T i
<br />/�
<br />) +�
<br />cl.nuuR1_, IM3TALLArICN, ETC.. p-
<br />Ftlo'MTY FEE - 5100,0(1 each SITE
<br />;1Du1,E» per YE?lF::,
<br />TOTAL —
<br />h_ _._.. - - _.__.._.... __..__..__._...
<br />...... .... _ ..... _....._
<br />...... .......
<br />..
<br />... ...... ....------- - -
<br />!C
<br />1936
<br />.__.._............................................................................_......._.................._..._..........._..._.........._...._.__....._.
<br />.......1 '3117
<br />1908
<br />1'389
<br />E CAlil; FEE _ $'l each TANK
<br />j
<br />Fl; Tanks t 50, 00
<br />-
<br />_...... _..........................................
<br />1''180
<br />I.,..................
<br />1981
<br />1'398
<br />198')
<br />IA!(�ultipfy-t;
<br />-
<br />by fee for
<br />.
<br />._....... ....... _..._..._............._....._........:....,......__.........
<br />_...
<br />�a!h year apPIiuble)
<br />[
<br />$
<br />L STATE SURCHARGE _ $56,00 each
<br />r {...._ ---
<br />.__......_.__.._...._.._...._.......—._......
<br />__._.....-
<br />TANK (see CA HEALTH 4 SAFETY CODE
<br />........................_..___.____..._......_....
<br />Sec 25281 for applicability)
<br />- ..._.__.._._.__.__._...__ ._......._.._._...._._.....
<br />Tj 1 Tanks s tJC, 0!i
<br />1326
<br />(981
<br />...-.......................--.........
<br />1908
<br />...... ... ..... _ - -
<br />- - - -- - -
<br />------ --
<br />IYI
<br />(anter a:10unt and Year)
<br />-.... ....... ........ .._....._..............
<br />................. ..._........_._....._._..
<br />......
<br />_... .... _._.__...
<br />...... _ _......-
<br />......._._.....
<br />.......---------- —
<br />t_._L
<br />_ ----- _—.._.. _........_....._..
<br />_........
<br />......... _....................
<br />- C—Mt IJ.. 1....._ ......
<br />.....
<br />...................................
<br />......-............................._................_.............._........................_..............._...
<br />C f'E A.11NT CLOSURE (Rcaoval or '1 osure-in-place)
<br />__.................................................................._..............._..............._.................. _.._...
<br />OiCLOSU2E FEE = 190.00 each TANK l Tanl;s � X 1,90.00
<br />-- - ---- -- ._.._.._... - - _ _..__...- ............... -............... ........ ...... .......... ......_..................-............-........... _...._.... _
<br />U. _--._..- - - - -.-- ..__... -- --..... .... .... .... ........... ......._........ ._... .............. .._....._.......__.... .... _................ _...__........ ._._ _..._.__.
<br />If TE,1PO7AFY CLOSURE' (Only allovcd one tine !ar up t,- tvo years)
<br />_.._....._._..__..._.........._._.._......_..... _....... ........ _..........I.._..._..._...._ .............. ... .... _....._ .............
<br />TE1PFJ?A%Y 1:L0 IT:E FEE = 520,00 each TA,11K s Tani ------
<br />s 1311,00
<br />_.....
<br />............... ...... ........... _........ ........ _........ .... .._.............._...._.... ...._......- - - -•---- — - -----..._. ---------�
<br />M PLAN Cl;EC1; (Installation or Repair)
<br />tI ---- �__......__........ _._.._... _ .... —_....._............ _......... _........ .............. ...... ........ -...... _.................. ............ .._...................... ... .............. ..... ......... ......_.....__.._..._.._..._...._._ ._...._...__ ---
<br />N PLAil CHECK FEE = $30,00 each SUUMI�SIOIIIRESU0111SS[Ohl5.
<br />............._._......_........_......_.......__._._.._...._......_..........._......._.._....._......_._._......__...._.......
<br />.......
<br />_..�—
<br />,. r....- --_------..._--............ _.....
<br />IprPntk l �
<br />E'CPAIR FEE _ {I10.(!0 each TA'IK I t Tanks z 5110,00
<br />--- ---•
<br />.____.__._-......___......._...._......... _........ _........................._....................................................................................._--,......_..._....._....._._..
<br />-.
<br />1� t? c ^Er tn'li ... e per 1:our, ninlmUM cine hour to be paid on plan subal ttai)
<br />[ I ._.....-._...,......__.._._........_......................_..._....._,...__........ __...__...... .............. ...... ....... -.....
<br />- - - -
<br />A PIPING R.PAC;,/CLU.,t!r, F.fa,-,r,L (Fees �r
<br />R I.INAUTHOEIZED RELEASE EVALUAT10"1 CONS1RUCTiON I�"ISF'ECTIUid SAf�'L[NG INtiPfCT1011
<br />�(�,rhen applicable) �(vhen applicable) �(vhen applicable)
<br />FEE _ ;"0, G('/hr I F F E = � 00/hl f `..E.. _._$..'..'..00/hr
<br />TOTAL DUE Is
<br />OFFICE USE My
<br />q7":i`"•r„v7:Tr :�I nl•��„ "r„rrr�ini1mr fi tr �nnn�,,p m q a �.r�
<br />I...r..
<br />n m'7 I , i
<br />�� aur n n r !i � ; i
<br />� ,,,,.m.,� �;;, ,, , ,,, � n,�,,,
<br />,� ,,, ,.,.,, �,.�
<br />�H'EEPS CC.1F LOC )'.ODE
<br />DIST COC-
<br />A�,Oi1NT DUE
<br />A�t(IUNT f:C.Y0 i'ilI.�;K,
<br />k/r:A H
<br />RC;'D DY
<br />DATE RECEI')ED
<br />_-�-fa�
<br />32a._
<br />s ...._..sem......._
<br />....._...�
<br />........._....�
<br />......... M[r I--
<br />
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