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LOU IUUAU SI UKAOt IANK YKUURAM ' ttt NURKSHEEI <br /> A FACILITY/SITE ME FACILITY CONTACT NAME <br /> C <br /> 1 <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA CODE U <br /> 1 C.1 <br /> Y CITY STAT ZIP CODE t of Tanks MAR 1 1989 <br /> J-� at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME IROIVMENTAL HEA TH <br /> P PERMIT/SERVICES <br /> P <br /> L <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE 1 WITH AREA CODE <br /> A <br /> N CITY STAT 1TP CODE TYPE of APPLICATION <br /> T1 1 CLOSURE. INOTALLATION. ETC. <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C <br /> T 1986 1987 1988 1989 <br /> V C) (D <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks x $50.00 1986 1987 1988 1989 <br /> A )multiply by fee for <br /> C each year applicable) ���� ` ��� I L�� — <br /> 1 F:� I $ c-) <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiouit and year) <br /> FTEMPORARY <br /> O L7 <br /> FEE = t90.rallowed <br /> 1 Tanks x $90.00 f <br /> CLOSURE ( time for up to two years) <br /> RY CLOSURE FEE = $90.00 each TANK 1 Tanks x $80.00 $ <br /> P PLAN CYECK (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 /> E 1 Tanks x $110.00 $ <br /> P _ <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 SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> IEE = $30.00/hr FEE = $35.00/hr FEE = $35.00/hr $ <br /> tt � <br /> OFFICE USE ONLY �j/� TOTAL DUE (A� <br /> SNEEPS 1 COMP 1 LOC CODE D[ST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 1 1 LL <br />