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I ROUND STORAGE TANK PROGRAM - FEE WORKSHEE' <br /> F FACILITYISITE NAME FACILITY CONTACT NAME <br /> 11 <br /> I1- _ <br /> L STREET ADDRESS I 'ITE PHONE 1 WITH AREA CODE <br /> I , 0 y -Z, Q i,�5_37J A6 �n <br /> Y CITY / STATE ZIP CODE t of Tanks <br /> VA- _._ CA `�5 1 at 5i ke it <br /> A APPLICANT/BILLG NAME — APPLICANT CONTACT NAME <br /> P <br /> FLA LL ` Ld <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> Pn <br /> T CITY STATE ZIP CODE TYPE ofAPPLICATIO)1 <br /> CLOSURES INSTALLATION, ETC.�� x <br /> VV �% i <br /> FACILITY FEE = 5100.00 each SITE ADDRESS per YEAR � I� TOTAL <br /> A <br /> T 1986 1987 1988 111989 <br /> _.- _ ✓ ;�� <br /> V - -- -W - --- <br /> E TANK FEE ^150.00 each TANK --.--_.._.-.- <br /> F II Tanks _ _ x 150.00 1986 1987 — 1988 — x— 1[1983 �,- --�� - <br /> A (multipTy V by fee for --— �. <br /> C each year applicable) �/ I} $ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> i 1 Tanks A x $56.00 1396 1187 1488 111989 <br /> Y (enter dnount and-year) - — - --——-- — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) _ <br /> L.. _ --- — — — — <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks z 190.'00 $ <br /> -� - <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) i <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks I; x $30,00 f <br /> IL PLAN CHECK (Installation or Repair) � '�l <br /> €A <br /> III PLAN CHECK FEE = $30.00 each SUBMISSIONIRESUDMISSION <br /> WIREPAIR <br /> R TANK, REPAIR FEE = $110.00 each TANK I Tanks <br /> p <br /> A PIPING REPAIR/CLOSUREIREMOVAL (Fees are per hour, minimum one hour to be paidion plan Submittal) — <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLINGI1INSPECT.,ION <br /> (when applicable) - (when applicable)--- (when applicable) <br /> FEE = $30.00/hr FEE = 135.001hr FEE _ $35'.00/hr <br /> Ik 'TOTAL DUE ,7 <br /> OFFICE USE ONLY <br /> +F <br /> fHTMIN9100 . MEMBER�II;1171MINIi�lllill 1 IFI�IiV��IfI0 I�illi�IlPViI�►�l�llill�I����'�falG�li�IQG�lu�41��Nlir�li! <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1IICASH RCVD BY DATE RECEIVED PERMIT 1 <br /> jy!j _._ 11 IC,' M u���V�i�i�iil�l'Q��l�, <br /> r <br />