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�.4011 -AWuloi LuCAL HEALTH DI' 4ICT <br /> 'JA6ERGROUNO STORAGE TANS PRnGRAM - FEE VORKSHE <br /> [ FACILITY/SITE NAME - - FACILITY CONTACT NAME <br /> A <br /> Q���� V evw I C� <br /> 1 SWEET s SITE PHONE $ <br /> .L S.Rt_ DORS; WITH AREA toom <br /> Y CITY STATq 1P CODE f of Tanks <br /> 5TU +t Site <br /> _ CA��.SLO� � _ <br /> AAPPLICANT/8!LLiNG NAM' (APPLICANT CONTACT NAME <br /> P <br /> P <br /> L11 <br /> ADDRESS APPLICANT PHONE E WITH AREA coot <br /> C <br /> IN CITY STAT 7IP CODE TYPE of APPLICATION <br /> Ti CLOSURE. 1ISTALLATION, ETC. <br /> FAC'-'"v FEE _ •!00.00 each ':TE ADDRESS per YEAR TOTAL <br /> C I 1986 198, 198A 1989 <br /> T —' <br /> I I !fid cvcv ZOC� <br /> E TAN'; 5200 each T <br /> F " Tanks i x '50.0@iR EIRD1987 1988 1989 <br /> A (mu!`.io*'� •,,, .EP for NOV --- i— <br /> C eat:: r* * appl:caF.le) ( pU 100 <br /> 1 ---- <br /> I STA-F rngrugRGE = f�j L16 I TH k SAFETY CODE Sec 25287 for applicability) <br /> IT�` T�-'c5 _ x $5h,n' [RU� F+G VtSIOA{981 1988 <br /> _ 1983 <br /> iYi(en�er r^ount an' v,:•) <br /> f <br /> C PERYANENT V OSURE rRPeovzl nr Closure-in-place) --- <br /> L - ----- <br /> 0 CLOSUP' FEE _ ^n,^^ rmc TANK f Tanks _ x $90.00 f <br /> S <br /> l� <br /> R TS PCRARY C'^SURE (Mlw allowed one tiee for up to two years) <br /> c_ <br /> TEMPno, r" "'^SURE TEE = +80.00 ezch TANK � I Tanks x $80.00 f <br /> P PLAN CPE^'; ' rs`a"ation or Renair) --- <br /> A <br /> N,PLAN C7f"( FEE = 530.00 each SUBMISSION/P,ESUBMTSSION f <br /> REPAY -' <br /> R TW oc""T.' ' _ 1410.00 each TANK ITanks x 1110.00 $ <br /> o�— --_—. —_— <br /> A'PrprNr r-,; 7/n rSURE/^EMOVAL (Fees are per hour, cininw one hour to be paid on plan submittal) <br /> I <br /> R UNItUTUOP77EM rricASE EVALUATION ICONSTP.UCTiON INSPECTION SAMPLING INSPECTION <br /> hen applicable) (when applicable) <br /> IEEE ' _I FEE_$35 00 FEE = f35.00/hr� f <br /> --- -- TOTAL DUE f Q <br /> 17fr RE ugr <br /> �Gq�" �uRm�mmDm�m!t�Vllflnnm�IUl��t!gml9N!�n�. I. I!p!���I��!Ill�pp�l��imn�ml _ <br /> CPMP p BLOC CODF. `.^T CODE AMOUNT TU- AMOUNT RCVD I CHECK 4/CASH RCVD BY DATE RECEIVED PERMIT I <br /> IG�til" 'r � �oi,ipp�Ahl p�o)pm � MI�H %Mi �p_ <br />