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tAC)L1IY CUhIACI NAME <br /> kY IAA LA.I! <br /> STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> T $ . , <br /> ' r clir Q� — 1-7z/�— X17 <br /> SifX-KTG/r CA STATE i1P CODE 1 of TANK'S <br /> j Sa 17 at Site 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT BANE <br /> P I' <br /> AA 14-7-0,14 <br /> 1 MAILING ADDRESS <br /> C A APPLICANT PHONE 1 (with Area Code) <br /> A Cllr -2 '9' <br /> TSTATE i1P CODE i <br /> Mvt7s���0� 2,4, 5361 losure InstA)lation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> L 1986 1987 1988 1989 <br /> T <br /> I <br /> v 1 <br /> E TANK FEE _ $50.00 each TANK <br /> F $ Tanks1 $50,00 1986 1987 1988 1989 <br /> A (eultiply-1-by fee for <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25281 for applicability) <br /> I <br /> 1 I Tanks r 156.00 1986 1981 )988 1989 <br /> Y (enter iioint and year) <br /> f <br /> C PERMANENT CLOSURE (Resoval or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks l s $90.00 f <br /> S CIO. UD <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = 160.00 each TANK 1 Tanks s $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE = 1110.00 each TANK <br /> P 1 Tanks_____ s $110.00 $ <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, einieue one hour to be paid on plan subeittil) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> when applicable) INSPECTION INSPECTION <br /> FEE = 130.00/hr FEE _ $35,00/hr FEE x $35.00/hr f <br /> f <br />' OFflCF USE ONtY TOTAL DUE <br /> mi <br /> LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CH 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> c <br />