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/ unl% JUAwUll,i LUL;AL HEALTH DISI-RICI" <br /> rt SZ'72z DERGROUND STORAGE TANK PROGRAM - FEE YORKSh, <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C,t'E/iTif� lam .' ' F !/,:>✓ i1G�f/ <br /> STREET ADDRESS �f� SITE I WITH Mlm• CDD[ <br /> T <br /> 9 � �- <br /> Y CITY ,C�j,�/(l STAT ZIP CODE 1 of Tanks <br /> at Site <br /> A APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> � <br /> S �QLv CY ��rA/72 LcS <br /> I MAILING ADDRESS J APPLICANT PHO 1 <br /> E �Q�� ��v YITN D[[. CDD[ <br /> N CITY <br /> STAT ZIP CODE Tm di <br /> / CIOSY[[. IwmTeLMT1oM [TC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> A — TOTAL <br /> C 1986 1987 1988 1989 <br /> /990 <br /> V f - <br /> E TANK FEE = 150.00 each TANK <br /> I I Tanks _ r 150.00 1986 1987 1988 <br /> A (wltipl I by fee (or 1989 �99L� <br /> C each year applicable) <br /> t L STATE SURCHARGE = 456.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25207 for applicability) <br /> T 1Tanks s (56.00 1986 1987 1988 <br /> Y (enter i'0unt and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK <br /> S 1 Tanks x 190.00 1 ��--- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK <br /> 1 Tanks _ r $80.00 1 <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 TANK REPAIR FEE _ $110.00 each TANK <br /> PI Tanks___ __ x 6110.00 <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 <br /> (when applicable) (when applicable) SAMPLING INSPECTION <br /> (when applicable) <br /> FEE = 130.00/hr FEE = 135.00/hr FEE = f35.00/hr <br /> I <br /> OFFICE USE OILY TOTAL DUE <br /> SNEEPS IF CON? 1 LOC CODE DIST CODE AMOUNT DUF AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> R R,I• ` — <br /> 717 <br /> 3 r i o � p . tlmim(ItltlII;I611puR(tltlRBMD91!Ogtl I; , �. <br /> v <br />