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RAna 0 R� n�oru 5 , <br /> ISTREET ADDRESS SITE PHONE 1 (with Area Code) <br /> F C ( r - 33 — G�Cv3 <br /> T CITY STATE IIP CODE 1 of TANK'S <br /> CA �i5�4o at Site 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> F <br /> P <br /> L O c <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE 1 (with Area Code) <br /> A <br /> N CITY <br /> T STATE TIP CODE TYPE of APPLICATION CLOSu �d <br /> (Closure, lnsta)latlon, etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 1986 1987 1988 1989 <br /> I <br /> V { <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks r 550,00 1986 1987 1988 1989 <br /> A I uItipTy-i-by lee for <br /> C each Year applicable) f <br /> I <br /> L STATE SURCHARGE = 156,00 each TANK (see CA HEALTH i SAFETY CODE Sec 25281 for applicability) <br /> T I Tanks s $56.00 1986 1981 1988 1989 <br /> Y (enter iiount and year) <br /> f <br /> C PERMANENT CL E-(Rewwal or Clowre-in-plan) <br /> L <br /> 0 CLOSURE F - 190.00 each TANK 1 iantt_ __ : 190.40 <br /> 5 <br /> U <br /> P TEMPORARY CLOSURE (Only allowed one tiee for up to two years) <br /> E <br /> 1EMPORARY CLOSURE FEE 180.00 each TANK 1 Tants s 180.00 { <br /> P PLAN CHECK (Installation or Rep ' � IN' <br /> L <br /> A (('' <br /> N PLAN CHECK FEE _ $30.00 each SSTON!'VNM <br /> SION { <br /> 'i <br /> REPAIR SAN JOAQU'N C01J <br /> S <br /> P <br /> E TANK REPAIR FEE _ $110.00 EhiP.LHEALTHO1Vi <br /> P SIL, 1 Tanks ___ $ 1110.00 f <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, einisue one hour to be paid on plan subeittall <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> I when applicable) INSPECTION INSPECTION <br /> FEE _ 130.001hri FEE ■ 1115.00/hr FEE a {35.00/hr f <br /> 1 <br /> OfFICf USE OMIY TOTAL DUE <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK ASH RCYD BY DATE RECEIVED PERMIT 1 <br /> -3/3 <br /> e0Or)yi7 <br />